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AmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.
Everything you need to know about your health plan
© 2015 AmeriHealth
AmeriHealth Insurance Company of New Jersey | AmeriHealth HMO, Inc.
Welcome to AmeriHealth New Jersey, Our goal at AmeriHealth New Jersey is to provide you with health care coverage that can help you live a healthy life. This Welcome Kit will help you understand your benefits so that you can take full advantage of your membership. To get the most from your coverage, it’s important to become familiar with the benefits and services available to you. You’ll find valuable information in this Welcome Kit on:
• how to use your ID card; • what services are and are not covered by your health insurance; • how decisions are made about what is covered; • how to use our member website, amerihealthexpress.com; • how to get in touch with us if you have a problem.
To register on our member website, visit amerihealthexpress.com. You may also download the free AmeriHealth New Jersey app, AHNJ on the GO, to your mobile phone, giving you easy access to your health info 24/7. If you have any questions, feel free to call Customer Service at 1-888-YOUR-AH1 (TTY:711) and we will be happy to assist you. Thank you for being a member of AmeriHealth New Jersey. We look forward to providing you with quality health care coverage.
Welcome Kit Overview How your plan works Introduction to your health plan .................................................................................................. 1
How to receive care ................................................................................................................... 2
Managing your health with amerihealthexpress.com .................................................................. 4
Customer support ...................................................................................................................... 5
Using your prescription benefits
Find out how to fill prescriptions ................................................................................................. 6
Find a pharmacy ........................................................................................................................ 6
Brand vs. generic ....................................................................................................................... 7
Mail order ................................................................................................................................... 8
Online services .......................................................................................................................... 9
Using your vision benefits
Your vision benefits .................................................................................................................. 11
Freedom of provider choice ...................................................................................................... 11
Choose from an extensive frame collection .............................................................................. 11
Coverage for contacts and laser correction .............................................................................. 11
Visionworks retail centers offer affordability, choice, and convenience ..................................... 12
How to read your Explanation of Benefits
Notice of Privacy Practices
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Introduction to your health plan
What is a primary care physician? A primary care physician (PCP) helps coordinate the overall medical care for you and your covered dependents. Your PCP is the doctor that will treat you for your basic health care needs.
Anytime you need to see a specialist, such as a cardiologist or dermatologist, your PCP may refer you to a specialist participating in the network. PCPs may choose a radiology, physical therapy, or laboratory site to which they refer their patients. If you need a service your PCP doesn’t provide, such as diagnostic testing or hospitalization, your PCP may refer you to an in-network facility.
How to search for PCP (HMO, HMO Plus or POS plan members only): Visit amerihealthnj.com/provider_finder where you can search by specialty (e.g. internal medicine or pediatrics), location, gender preference, and/or distance.
How to choose or change your PCP (HMO, HMO Plus or POS plan members only):
Two ways to choose or change your PCP:
Online: To select or change your doctor, visit amerihealthexpress.com, our simple, convenient, and secure member website.
Phone: Call 1-888-YOUR-AH1 (TTY:711) and one of our Customer Service associates will take your PCP selection over the phone.
Please note: POS+, PPO or EPO plan members do not need to select a PCP.
Using your ID card
You and your covered dependents will each receive an AmeriHealth New Jersey identification (ID) card. It is important to take your ID card with you wherever you go because it contains information including what to pay when visiting your doctor, specialist, or the emergency room (ER). You should present your ID card when you receive care, including doctor visits or when checking in at the ER.
The back of your ID card provides information about medical services, what to do in an emergency situation, and how to use your benefits.
If any information on your ID card is incorrect, you misplace an ID card, or need to print out a temporary ID card, you may do so through amerihealthexpress.com or by calling 1-888-968-7241 (TTY:711).
Got Questions? Call 1-888-YOUR-AH1 (TTY:711)
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Scheduling an appointment Simply call your doctor’s office and request an appointment. If possible, notify your doctor 24 hours in advance if you are unable to make it to a scheduled appointment.
Referrals If you have an HMO or POS plan, you are required to get a referral from your PCP for certain specialty services. You may check the status of a referral by logging on to amerihealthexpress.com, or on your mobile device through the AmeriHealth New Jersey mobile app.
Please note: referrals are not required for members with HMO Plus, POS Plus, EPO or PPO plans.
Locating a network physician or hospital
You have access to our expansive provider network of physicians, specialists, and hospitals. You may search our provider network by going to www.amerihealthnj.com/provider_finder. You may search by specialty (e.g. internal or pediatrics), location, gender preference, and/or distance. You may also call 1-888-968-7241 (TTY:711) and a Customer Service associate will help you locate a provider.
Using your preventive care benefits
Quality care and prevention are vital to your long-term health and well-being. That’s why we cover 100% of certain preventive services, including, but not limited to:
• Screenings for: – breast, cervical, and colon cancer – vitamin deficiencies during pregnancy – diabetes – high cholesterol – high blood pressure
• Routine vaccinations for children, adolescents, and adults as determined by the CDC (Centers for Disease Control and Prevention)
• Women’s preventive health services, such as: – well-woman visits (annually); – screening for gestational diabetes; – human papillomavirus (HPV) DNA testing; – counseling for sexually transmitted infections; – counseling and screening for human immunodeficiency virus (HIV); – screening and counseling for interpersonal and domestic violence; – breastfeeding support, supplies (breast pumps), and counseling; – generic formulary contraceptives, certain brand formulary
contraceptives, and FDA-approved over-the-counter female contraceptives with a prescription.
Be sure to consult with your PCP for preventive services and / or screenings.
Quality care and prevention are vital to your long-term health and well-
being.
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Wellness Guidelines
One of the best ways to stay well is to utilize the preventive services covered by your health plan. A recommended schedule of wellness visits to your health care provider is outlined in our Wellness Guidelines*. To download our Wellness Guidelines, log on to amerihealthexpress.com or call 1-888-968-7241 (TTY:711) to request a hard copy.
If you need to seek care outside of normal business hours, the following options are available:
Emergency care In the event of an emergency, go immediately to the emergency room. If you believe your situation is particularly severe, call 911 for assistance.
A medical emergency is thought of as a medical or psychiatric condition in which symptoms are so severe, that the absence of immediate medical attention could place one’s health in jeopardy.
For most minor injuries or illness, a hospital emergency room is not the most appropriate place for you to be treated. Hospital emergency rooms provide emergency care and must prioritize patients’ needs. The most seriously hurt or ill patients are treated first. If you are not in that category, you may wait a long time.
Urgent Care
Urgent care is necessary treatment for a non-life-threatening, unexpected illness or accidental injury that requires prompt medical attention when your doctor is unavailable. Examples include sore throat, fever, sinus infection, ear ache, cuts, rashes, sprains, and broken bones.
You may visit an urgent care center which offers a convenient, safe, and affordable treatment alternative to emergency room care when you can’t get an appointment with your own doctor.
Retail health clinic Retail health clinics are another alternative when you can’t get an appointment with your own doctor for non-emergency care. Retail health clinics use certified nurse practitioners who treat minor, uncomplicated illness or injury. Some retail health clinics may also offer flu shots and vaccinations.
Using services that require preapproval Certain services may require preapproval prior to receiving care to ensure that the services you seek are medically necessary. Learn more at amerihealthnj.com/precert.
*The Wellness Guidelines are a summary of recommendations based on the U.S. Preventive Services Task Force and other nationally recognized sources. These recommendations have been reviewed by our network health care providers. This information is not a statement of benefits. Please refer to your health benefit plan contract/member handbook or benefits handbook for terms, limitations, or exclusions of your health benefits plan. Please contact our Customer Service department with questions about which preventive care benefits apply to you. The telephone number for Customer Service can be found on your ID card.
When to go to the ER: • heart attack • electrical burn When to go to an urgent care center: • sore throat • ear ache
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Receiving services for mental health or substance abuse treatment Magellan Behavioral Health administers your mental health and substance abuse benefits. They can be reached by calling Customer Service at 1-888-968-7241 (TTY:711). Refer to the terms and conditions of your health plan to find out if you have coverage for mental health and substance abuse benefits.
Managing your health with amerihealthexpress.com On amerihealthexpress.com, you can conveniently and securely view your benefits and claims information, in addition to having access to tools that help you take control of your health. As an AmeriHealth New Jersey member, you and your dependents who are 14 years of age or older can create personal accounts on amerihealthexpress.com.
Register on amerihealthexpress.com To register, simply go to amerihealthexpress.com, click Register, and then follow the on-screen directions. Be sure to have your ID card present as it has information that you will need to register.
Once you’re registered, log on to amerihealthexpress.com to:
• view your benefits information; • review claims information; • review annual out-of-pocket expenses; • request a replacement ID card and/or print a temporary ID card; • download forms.
Online tools to help make informed health care decisions
Amerihealthexpress.com also provides you with tools and resources to help you make informed health care decisions:
• Provider Finder and Hospital Finder help you find the participating doctors and hospitals that are equipped to handle your needs. Simple navigation helps you get fast and accurate results. When you select your health plan type, your results are customized based on your network, making it easy to locate a participating doctor, specialist, hospital, or other medical facility nearby. You’ll even be able to read patient ratings and reviews, in addition to rating your doctors and writing your own reviews.
• Symptom checker provides a comprehensive tool to help you understand your symptoms and what to do about them.
• Health Encyclopedia provides information on more than 160 health topics, plus the latest news on common conditions.
• Treatment Cost Estimator helps you estimate your costs within certain geographic areas for hundreds of common conditions, including tests, procedures, and health care visits, so that you can plan and budget for your expenses.
Register on amerihealthexpress.com to access your benefits
online.
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• Personal Health Profile gives a clear picture of what you are doing right, plus ways to stay healthy. After completing the Personal Health Profile, you will receive a confidential and personalized action plan.
• My Health Assistant is a personal coaching tool that provides an interactive, targeted approach to making healthy lifestyle changes.
• Health Trackers allow you to track your blood pressure, cholesterol, body fat, and exercises.
• Personal Health Record helps you store, maintain, track, and manage your health information in one centralized and secure location.
Customer Support When you need us, we’re here for you. You can contact us to discuss anything pertaining to your health care, including benefits and eligibility, claims status, requesting a new ID card, or wellness programs.
To send a secure email to Customer Service, log on to amerihealthexpress.com and click on Contact us.
Mail AmeriHealth New Jersey 259 Prospect Plains Road, Building M Cranbury, NJ 08512
Call
Call 1-888-968-7241 (TTY:711) to speak to one of our Customer Service members Monday through Friday, 8 a.m. to 6 p.m.
Language Services
Para obtener asistencia en Español, por favor comuníquese con el
Servicio de Atención al Cliente al número que figura en su tarjeta de identificación.
Upang makakuha ng tulong sa Tagalog, tumawag sa numero ng telepono
ng serbisyong pangkostumer na nakalista sa iyong card ng pagkikilanlan.
Táá Diné k’ehjí shíka ’adoowoł nínízingo, ninaaltsoos bee ééhózinígíí béésh bee hane’é bikáá’ bee bik’e’ashchínígíí bich’i’ hodíílnih.
If you have trouble hearing or speaking, call 711 and Customer Service can assist you through TDD or TTY.
Member Rights & Responsibilities To obtain a list of Rights and Responsibilities, log onto http://www.amerihealthnj.com/html/members/quality_management/rights_responsibilities.html or call the Customer Service number on your ID Card.
Your one-stop shop. amerihealthexpress.com
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Using your prescription drug benefits The information in this section is only applicable to members who have AmeriHealth New Jersey prescription (RX) coverage.
AmeriHealth New Jersey Prescription Drug Program If you have an AmeriHealth New Jersey Prescription Drug plan, your benefits are administered by FutureScripts®. FutureScripts helps you easily and safely obtain the prescription drugs you need at an affordable price.
Take a look at the advantages:
• Easy to use. A national network of retail pharmacies will recognize and accept your member ID card.
• Low out-of-pocket expenses. When you use a participating pharmacy, your out-of-pocket costs are based on a discounted price, fixed copayments, or coinsurance.
• No paperwork. You don’t have to file a claim form or wait for reimbursement when you use a participating pharmacy.
• High level of safety. When you fill a prescription at a participating pharmacy, your pharmacy can identify harmful drug interactions and other dangers by viewing your drug history.
• To get maintenance drugs needed to treat ongoing or chronic conditions, you have the following options:
– Home delivery. Your program may allow you to receive drugs right at your door when ordered through the mail order service, eliminating time spent waiting in line at the pharmacy counter.
– Mail order purchases allow you to get a larger supply of drugs than what might be available to you at the retail pharmacy. Additionally, depending upon your plan design, your out-of-pocket expenses may be lower, and you won’t have to visit the pharmacy as often.
How to fill your prescription at a retail pharmacy Present your member ID card and your prescription at a FutureScripts-participating pharmacy. The pharmacist will confirm your eligibility for benefits and determine your share of the cost for your prescription (copay). Your doctor may also be able to submit your prescription to your pharmacy electronically.
Find a pharmacy Visit futurescripts.com or call the number on your member ID
card.
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Participating pharmacies If a pharmacy is in your plan’s network, it is considered to be a participating pharmacy. When you’re traveling, you will find that most pharmacies in all 50 states accept your member ID card and can fill your prescription for the same cost that you would pay at your local pharmacy back home. There is no need to select just one pharmacy to fill your prescription needs.
To locate a participating pharmacy, visit futurescripts.com or call the number on your member ID Card.
Non-participating pharmacies If a prescription covered by your plan is filled at a pharmacy that does not participate in the FutureScripts network, you will have to pay the pharmacy’s regular cost at the counter. Then, you may submit a claim form for partial reimbursement to:
FutureScripts Dept. #0382 P.O. Box 419019 Kansas City, MO 64141
Your reimbursement check should arrive within 14 days from the day your claim form is accepted.
When you use a non-participating pharmacy that has not agreed to charge a discounted price, it may cost you more money.
Understanding your prescription Brand drugs are only manufactured by one company, which advertises and sells its product under a unique trade name. In many cases, brand drugs are quite expensive, which is why your share of the cost is higher. Generic drugs are typically manufactured by several companies and are almost always less expensive than the brand drug. Generic drugs are approved by the U.S. Food and Drug Administration (FDA) to ensure they are as safe and effective as their brand counterparts. However, not every brand drug has a generic version.
The Select Drug Program® provides our members with comprehensive prescription drug coverage. The Select Drug Program uses a formulary, which includes all generic drugs and a defined list of brand drugs that have been evaluated for their medical effectiveness, positive results, and value. The formulary is reviewed quarterly to ensure its continued effectiveness. To check the formulary status of drugs, simply log on to amerihealthexpress.com.
In addition to the Select Drug Program formulary, you will also find helpful information on these related topics:
• Prior authorization process • Age and gender limits • Quantity level limits
Brand vs. Generic Generic drugs are as effective as brand drugs and could save you money. However, consult your doctor to find out which drug type is best for you.
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If you’re not sure if brand or generic drugs are right for you, talk to your doctor. The pharmacist may discuss with your physician whether an alternative drug might be appropriate for you. Let your physician know if you have a question about a change in your prescription(s) or if you prefer the original prescription(s).
Certain controlled substances and other prescribed medications may be subject to dispensing limitations. If you have any questions regarding your medication, please call Customer Service at 1-888-968-7241 (TTY:711).
Preventive drugs for adults and children AmeriHealth New Jersey’s prescriptive drug plans include 100% coverage for preventive medications when received from an in-network pharmacy. This means that you won’t have to pay copays, coinsurance, or deductibles for certain preventive medications with a prescription from your doctor. Receiving this preventive care will help you stay healthy and may improve your overall health.
For a list of preventive drugs eligible please visit amerihealthexpress.com or call the phone number on the back of your member ID card.
Mail order pharmacy If your doctor has prescribed a medication that you’ll need to take regularly over a long period of time, the mail order service is an excellent way to get a long-lasting supply and reduce your out-of-pocket costs.
Mail order is convenient and safe to use
If you choose mail order, you can get up to three times the number of doses at one time, as opposed to picking up one dose at the pharmacy.
Mail order prescriptions have been safely handled through the mail for many years. When your order is received, a team of registered, licensed pharmacists check your prescription against the record of all drugs dispensed to you by a FutureScripts network pharmacy. This process ensures that every prescription is reviewed for safety and accuracy before it is mailed to you.
If there are questions about your prescription, a pharmacist will contact your doctor before your medication is dispensed. Your medication will be sent to your home within ten days from the date your complete, eligible order is received.
There may be times when you need a prescription right away. On these occasions, you should have your prescription filled at a local participating pharmacy. If you need a medication immediately, but will be taking it on an ongoing basis, ask your doctor to write two separate prescriptions; you can have the first prescription filled locally for an initial 30-day supply. Then you can send the second prescription to FutureScripts for a 90-day supply provided through the mail.
Mail order is convenient and safe to
use
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How to begin using mail order pharmacy:
1. When you are prescribed a chronic or “maintenance” drug therapy, ask your doctor to write the prescription for a 90-day supply, plus refills. Make sure your doctor knows that you have a mail order service so that you get one 90-day prescription and not three 30-day prescriptions, because the cost of the three 30-day prescriptions may be more than the cost for one 90-day prescription. If you’re taking medication now and would like to begin using mail order pharmacy, ask your doctor for a new prescription.
2. Complete the FutureScripts Mail Service Order Form with your first order only. Forms and envelopes are available by calling the number on your member ID card.
3. Be sure to answer all the questions, and include your member ID number. An incomplete form can cause a delay in processing. Send the completed Mail Service Order Form, your original 90-day prescription, and the appropriate payment to FutureScripts.
4. Your mail order request will be processed and your medication sent to you within ten days from the day you mail your order, along with instructions for future refills. Standard shipping is free of charge through U.S. Mail. Narcotic substances and refrigerated medicines will be shipped by FedEx® at no additional cost to you.
You will be dispensed the lower-priced generic drug (if manufactured) unless your doctor writes “brand medically necessary” or “dispense as written” on your prescription, or if you indicate that you do not want the generic version of your brand drug on the Mail Service Order Form. A Mail Service Order Form and envelope will be included with each mail order delivery.
Paying for mail order services Your payment can be in the form of a check or money order (made payable to FutureScripts), or you can complete the credit card portion of the Mail Service Order Form. FutureScripts accepts Visa, MasterCard®, Discover®, and American Express®. Please do not send cash. If you are uncertain of your payment, call the number on the back of your member ID card. If the payment you enclose is incorrect, you will be sent either a reimbursement check or an invoice, as appropriate.
If you have any questions about your AmeriHealth New Jersey Prescription Drug program,
call 1-888-968-7241 (TTY:711).
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Mail order refills
When you receive a medication through the mail order service, you will also receive a notice showing the number of refills allowed by your doctor. To avoid the risk of being without your medication, mail the refill notice and your payment two weeks before you expect your present supply to run out. You can also manage and order your refills online through amerihealthexpress.com.
The refill notice will include the date when you should reorder your medication, as well as the number of refills you have left. Remember, most prescriptions are valid for a maximum of one year.
If you have any questions concerning this program, please contact FutureScripts at 1-888-678-7012 (TTY:711).
Self-administered Specialty Drug Coverage
Self-injectables and other oral specialty drugs that can be administered by you, the patient, or by a caregiver outside of the doctor’s office are covered under your AmeriHealth New Jersey prescription drug benefits administered by FutureScripts. You may also fill your prescription via the FutureScripts Direct Ship Specialty Pharmacy Program.
The administration of a self-injectible drug by a medical professional is covered under your AmeriHealth New Jersey medical benefit, even if you obtained the self-injectable drug through the FutureScripts Specialty Pharmacy Program. However, the drug itself will be covered under your AmeriHealth New Jersey prescription drug benefit.
Unless otherwise noted in your Benefit Booklet, the only self-injectable drugs that are covered under AmeriHealth New Jersey medical plans include drugs that:
are required by law to be covered under both medical benefits and pharmacy benefits (e.g., insulin)
are required for emergency treatment, such as self-injectables that counteract allergic reactions (e.g., EpiPen)
An independent pharmacy benefits management (PBM) company, FutureScripts, administers our prescription drug benefits and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. AmeriHealth New Jersey anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefit plans, prescription drugs are subject to a member copayment.
Manage and order your refills online amerihealthexpress.com
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Using your vision Benefits The information in this section is only applicable to members who have AmeriHealth New Jersey vision coverage.
Your vision benefits Vision problems are among the most prevalent health issues in the United States. Nearly 176 million American adults wear some form of vision correction.* An eye exam can help prevent vision problems and help detect more serious chronic health conditions, such as diabetes, hypertension, and heart disease.
Your vision plan gives you access to timely treatment and covered services like refraction, glaucoma screenings, and dilation that can help paint a picture of your overall health. Please review your Benefit Booklet to confirm if you have vision coverage, as well as applicable benefits and limitations.
Freedom of provider choice You have access to the Davis Vision provider network, which includes more than 36,000 ophthalmologists, optometrists, and regional and national retailers, including Visionworks.
Choose from an extensive frame collection You can select any frame from the Exclusive Frame Collection of stylish, contemporary frames covered in full, or with a minimal copay. You also have the freedom to use your frame allowance toward any frame on the market at any network location. This includes Visionworks, which has over 2,000 frames from which to choose.
Every frame or lens purchased at a participating provider is backed by an unconditional one-year breakage warranty for repair or replacement.
Coverage for contacts and laser vision correction You can purchase replacement contact lenses through LENS123®, a mail order contact lens replacement program. Replacement contact lenses or contact lense solution will be shipped same day by LENS123, and you can feel good knowing you are guaranteed low prices.
If you’re interested in Laser Vision Correction, you may be eligible to receive up to 25% off a participating provider’s usual and customary fees, or 5% off any participating provider’s advertised specials on laser vision correction services.
You can also view your benefits, check eligibility, locate a participating provider, or view the Davis Vision Collection of frames online through amerihealthexpress.com.
The clear solution to
your vision care needs
View your benefits online
amerihealthexpress.com
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Visionworks retail centers offer affordability, choice, and convenience Visionworks optical retail centers are a cornerstone of the provider network and support AmeriHealth New Jersey’s commitment to choice. Visionworks has high-quality eyeglasses, designer frames, and a wide variety of contact lenses, reading glasses, and specialty lenses all at great prices. With a dedication to quality, durability, and variety, Visionworks provides you with everything that you need to find the right look. Visionworks also has one of the largest selections of fun and fashionable children’s eyeglasses in the eyewear industry. Children 13 years of age or younger receive free impact and scratch-resistant lenses.
With your AmeriHealth New Jersey Vision Care benefits, you will receive:
high-quality designer and exclusive brands frames
eyeglass lenses
contact lenses
sunglasses
vision correction
*VisionWatch - The Vision Council Member Benefit Reports, The Vision Council & Jobson, 12ME September 2009
AmeriHealth New Jersey Vision is administered by Davis Vision. An affiliate of AmeriHealth has a financial interest in Visionworks.
To find a Visionworks near you, visit visionworks.com.
How to read your Explanation of Benefits Our Explanation of Benefits statements (commonly referred to as an EOB) help you understand your out-of-pocket costs when you receive covered services. The easy-to-read format lets you quickly find out how much a doctor, hospital, or other health care facility charged for services, what your AmeriHealth New Jersey health plan paid, and how much you owe.
Questions about your EOB? Call the phone number on the back of your member ID card. Be sure to have your member ID number and EOB ready when you call.
New paperless EOB Option You can view your EOB online at amerihealthexpress.com or have it sent to you by email. You can also continue to receive a paper copy by mail. Just log on to amerihealthexpress.com to select your preferences.
Health Plan Pays: The actual dollar calculation of the amount AmeriHealth New Jersey pays.
5 We Sent Check to: Individual/facility that received the AmeriHealth New Jersey reimbursement check.
1
Provider May Bill You: Summary of what you owe the provider. The individual breakdown is shown in the Member Responsibility section.
Your Share of Amount Remaining: The amount remaining after AmeriHealth New Jersey’s payment has been subtracted.
2 6
Provider Charges: The amount the provider actually charged for services.
Amount You Owe Provider: The total of all of member responsibilities. This includes any deductable, coinsurance, or copayment amounts, plus any remaining amounts.
3 7
Remarks: Explains why certain charges were not covered (if any).
Our Allowance: Amount covered by AmeriHealth New Jersey. 8 4
AMERIHEALTH HMO, INC. HMO PLAN
SMALL GROUP HEALTH MAINTENANCE ORGANIZATION EVIDENCE OF COVERAGE
HMO GOLD REGIONAL PREFERRED 308 OFFX AmeriHealth HMO, Inc. certifies that the Employee named below is entitled to Covered Services and Supplies described in this Evidence of Coverage, as of the effective below, subject to the eligibility and effective date requirements of the Contract.
The Contract is an agreement between AmeriHealth HMO, Inc. and the Contractholder. This Evidence of Coverage is a summary of the Contract Provisions that affect Your Coverage. All Covered Services and Supplies and Non-Covered Services and Supplies are subject to the terms of the Contract.
CONTRACTHOLDER: GROUP CONTRACT NUMBER: EMPLOYEE: CERTIFICATE NUMBER: EFFECTIVE DATE OF EVIDENCE OF COVERAGE: COVERED CLASSES: All Employees of the Contractholder (and its Associated Companies) who permanently live, work or reside in the Service Area and are eligible or covered under the Group Care Health Plan.
SERVICE AREA: The State of New Jersey
AFFILIATED COMPANIES: none
COST OF THE COVERAGE:
The coverage in this Evidence of Coverage is Contributory Coverage. You will be informed of the amount of Your contribution when You enroll. HMO’s Address: AmeriHealth HMO, Inc 259
Prospect Plains Road, Bldg M Cranbury, NJ 08512-3706
This Evidence of Coverage replaces any older Evidence of Coverage issued to You for the Group Health Care Plan.
AmeriHealth HMO, Inc (Amerihealth) Telephone: 888-968-7241 (TTY: 711) FAX: 1-888-457-9013 Email: www.amerihealth.com/inquiry 10148909
TABLE OF CONTENTS Section Page SCHEDULE OF SERVICES AND SUPPLIES………………………………………... 1 DEFINITIONS…………………………………………………………………………….. 5 ELIGIBILITY………………………………………………………………………………. 20 MEMBER PROVISIONS………………………………………………………………… 28 COVERED SERVICES AND SUPPLIES……………………………………………… 39 NON-COVERED SERVICES AND SUPPLIES……………………………………….. 52 COORDINATION OF BENEFITS AND SERVICES………………………………….. 56 GENERAL PROVISIONS……………………………………………………………….. 63 CONTINUATION RIGHTS………………………………………………………………. 65 MEDICARE AS SECONDARY PAYOR……………………………………………….. 77 STATEMENT OF ERISA RIGHTS……………………………………………………… 79
10006712, 10006858
SCHEDULE OF SERVICES AND SUPPLIES The services or supplies covered under this Contract are subject to the Copayments, Deductible and Coinsurance set forth below and are determined per Calendar Year per Member, unless otherwise stated. Maximums only apply to the specific services provided. COPAYMENT
For Preventive Care NONE
For all other Primary Care Physician Visits $30 per visit
Maternity (pre-natal care) NONE
Specialist Services $60 per visit
Complex Imaging Services $100 Copayment/visit/Member
All Other Diagnostic Services
Inpatient $0 Copayment
Outpatient $50 Copayment/visit/Member
Laboratory Services $0 Copayment/visit/Member
Emergency Room $100 Copayment/visit/Member (waived if admitted within 24 hours)
Note: The Emergency Room Copayment is payable in addition to the applicable Copayment, Deductible and Coinsurance, if any.
Urgent Care $85 Copayment/visit/Member
Hospital Services Inpatient $500 Copayment/day for a maximum of 5 days/admission
Maximum Copayment $5,000/Calendar Year. Unlimited Days
Skilled Nursing Facility/ Extended Care Center
$500 Copayment/day for a maximum of 5 days/admission
Facility Charges for Outpatient Surgery $250 Copayment/visit/Member
Therapeutic Manipulations $50 Copayment/visit; Maximum 30 visits/Calendar Year
10006712, 10006858
Therapy Services:
Physical, Occupational, Speech, Cognitive Therapy
$50 Copayment/visit/Member
Cardiac/Respiration Therapy $60 Copayment/visit/Member
Chemotherapy/Radiation Therapy $0 Copayment/visit
Mental Health Care Inpatient $500 Copayment/day for a maximum of 5 days/admission
Mental Health Care Outpatient $60 Copayment/visit/Member
Treatment of Substance Abuse Inpatient $500 Copayment/day for a maximum of 5 days/admission
Treatment of Substance Abuse Outpatient $60 Copayment/visit/Member
Vision Benefits (for Members through the end of the month in which the Member turns age 19)
Eye exam (once every 12 months) Covered 100%
Eyeglass lenses (once every 12 months) Covered 100%
Standard frames (once every 12 months) Covered 100%
Food and Food Products for Inherited
Metabolic Diseases
$50 Copayment
Nutritional Counseling $0
For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections
DEDUCTIBLE PER CALENDAR YEAR
For Primary Care Physician Visits including Preventive Care and immunizations and lead screening for children
NONE
Maternity (pre-natal care) NONE
Second Surgical Opinion NONE
For all other Covered Services and Supplies
Per Member NONE
Per Covered Family NONE
COINSURANCE
For Preventive Care: 0%
For Durable Medical Equipment 50%
For all services and supplies to which a
Copayment does not apply
0%
For all services and supplies to which a
Copayment applies
NONE
10006712, 10006858
MAXIMUM OUT OF POCKET
Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.
The Maximum Out of Pocket for this Contract is as follows:
Per Member per Calendar Year $6,600
Per Family per Calendar Year $13,200
Note: The Maximum Out of Pocket cannot be met with Non-Covered Charges.
10006712, 10006858
LIMITATIONS ON SERVICES AND SUPPLIES Home Health Care 60 visits per Calendar Year, subject to Pre-Approval Hospice Services Unlimited days, subject to Pre-Approval. Speech and Cognitive Therapy (Combined) 30 visits per Calendar Year See below for the separate speech therapy benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision. Physical and Occupational Therapy (Combined) 30 visits per Calendar Year See below for the separate benefits available under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision. Charges for speech therapy provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision 30 visits Note: The 30 – visit limit does not apply to the treatment of autism. Charges for physical and occupational provided under the Diagnosis and Treatment of Autism and Other Developmental Disabilities Provision (combined benefits) 30 visits
Note: The 30 – visit limit does not apply to the treatment of autism. Therapeutic Manipulation 30 visits per Calendar Year Skilled Nursing Facility/ Extended Care Center
Unlimited days, subject to Pre-Approval
NOTE: NO SERVICES OR SUPPLIES WILL BE PROVIDED IF A MEMBER FAILS TO OBTAIN A REFERRAL FOR CARE THROUGH HIS OR HER PRIMARY CARE PHYSICIAN OR THE CARE MANAGER. READ THE MEMBER PROVISIONS CAREFULLY BEFORE OBTAINING MEDICAL CARE, SERVICES OR SUPPLIES. REFER TO THE SECTION OF THIS CONTRACT CALLED "NON-COVERED SERVICES AND SUPPLIES" FOR A LIST OF THE SERVICES AND SUPPLIES FOR WHICH A MEMBER IS NOT ELIGIBLE FOR COVERAGE UNDER THIS CONTRACT.
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DEFINITIONS The words shown below have specific meanings when used in the Contract. Please read these definitions carefully. Throughout the Contract, these defined terms appear with their initial letters capitalized. They will help Members understand what services and supplies are provided. ACCREDITED SCHOOL. A school accredited by a nationally recognized accrediting association, such as one of the following regional accrediting agencies: Middle States Association of Colleges and Schools, New England Association of Schools and Colleges, North Central Association of Colleges and Schools, Northwest Association of Schools and Colleges, Southern Association of Colleges and Schools, or Western Association of Schools and Colleges. An accredited school also includes a proprietary institution approved by an agency responsible for issuing certificates or licenses to graduates of such an institution. AFFILIATED COMPANY. A company defined in subsections (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986. All entities that meet the criteria set forth in the Internal Revenue Code shall be treated as one employer. ALLOWED CHARGE. Means an amount that is not more than the lesser of: • the allowance for the service or supply as determined by Us, based on a standard approved by the Board; or • the negotiated fee schedule. The Board will decide a standard for what is an Allowed Charge under this Contract. Please note: The Coordination of Benefits and Services provision includes a distinct definition of Allowed Charge. AMBULANCE. A certified transportation vehicle for transporting Ill or Injured people that contains all life-saving equipment and staff as required by applicable state and local law. AMBULATORY SURGICAL CENTER. A Facility mainly engaged in performing Outpatient Surgery. It must: a) be staffed by Practitioners and Nurses, under the supervision of a Practitioner; b) have operating and recovery rooms; c) be staffed and equipped to give emergency care; and d) have written back-up arrangements with a local Hospital for emergency care. It must carry out its stated purpose under all relevant state and local laws and be either: a) accredited for its stated purpose by either the Joint Commission or the Accreditation Association for ambulatory care; or b) approved for its stated purpose by Medicare. A Facility is not an Ambulatory Surgical Center, for the purpose of the Contract, if it is part of a Hospital.
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ANNIVERSARY DATE. The date which is one year from the Effective Date of the Contract and each succeeding yearly date thereafter. BIRTHING CENTER. A Facility which mainly provides care and treatment for women during uncomplicated pregnancy, routine full-term delivery, and the immediate post-partum period. It must: a) provide full-time Skilled Nursing Care by or under the supervision of Nurses; b) be staffed and equipped to give emergency care; and c) have written back-up arrangements with a local Hospital for emergency care. It must: a) carry out its stated purpose under all relevant state and local laws; or b) be approved for its stated purpose by the Accreditation Association for Ambulatory Care; or c) be approved for its stated purpose by Medicare. A Facility is not a Birthing Center, for the purpose of the Contract, if it is part of a Hospital. BOARD. The Board of Directors of the New Jersey Small Employer Health Benefits Program. CALENDAR YEAR. Each successive twelve-month period starting on January 1 and ending on December 31. CHURCH PLAN. Has the same meaning given that term under Title I, section 3 of Pub.L.93-406, the “Employee Retirement Income Security Act of 1974” COINSURANCE. The percentage of Covered Services or Supplies that must be paid by a Member. Coinsurance does not include Copayments. COMPLEX IMAGING SERVICES. Any of the following services: a) Computed Tomography (CT), b) Computed Tomography Angiography (CTA), c) Magnetic Resonance Imaging (MRI), d) Magnetic Resonance Angiogram (MRA), e) Magnetic Resonance Spectroscopy (MRS) f) Positron Emission Tomography (PET), g) Nuclear Medicine including Nuclear Cardiology. CONTRACT. The Contract, including the application and any riders, amendments or endorsements, between the Contractholder and AmeriHealth HMO, Inc. CONTRACTHOLDER. Employer or organization which purchased the Contract. COPAYMENT. A specified dollar amount which Member must pay for certain Covered Services or Supplies. NOTE: The Emergency Room Copayment, if applicable, must be paid in addition to any other Copayments. COSMETIC SURGERY OR PROCEDURE. Any surgery or procedure which involves physical appearance, but which does not correct or materially improve a physiological function and is not Medically Necessary and Appropriate.
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COVERED EMPLOYEE. A person who meets all applicable eligibility requirements, enrolls hereunder by making application, and for whom premium has been received. COVERED SERVICES OR SUPPLIES. The types of services and supplies described in the Covered Services and Supplies section of the Contract. Read the entire Contract to find out what We limit or exclude. CURRENT PROCEDURAL TERMINOLOGY (C.P.T.) The most recent edition of an annually revised listing published by the American Medical Association which assigns numerical codes to procedures and categories of medical care. CUSTODIAL CARE. Any service or supply, including room and board, which: a) is furnished mainly to help Member meet Member's routine daily needs; or b) can be furnished by someone who has no professional health care training or skills. Even if a Covered Person is in a Hospital or other recognized Facility, We do not provide for that part of the care which is mainly custodial. DEPENDENT. Your: a) legal spouse which shall include a civil union partner pursuant to P.L. 2006, c. 103 as well
as same sex relationships legally recognized in other jurisdictions when such relationships provide substantially all of the rights and benefits of marriage; except that legal spouse shall be limited to spouses of a marriage as marriage is defined in Federal law with respect to:
the provisions of the Policy regarding continuation rights required by the Federal Consolidated Omnibus Reconciliation Act of 1996 (COBRA), Pub. L. 99-272, as subsequently amended; and
The provisions of this Contract regarding Medicare Eligibility by Reason of Age and Medicare Eligibility by Reason of Disability.
b) Dependent child through the end of the month in which he or she attains age 26. Note: If the Contractholder elects to limit coverage to Dependent Children, the term Dependent excludes a legal spouse. Under certain circumstances, an incapacitated child is also a Dependent. See the Eligibility section of the Contract. Your " Dependent child" includes Your legally adopted child, Your step-child, Your foster child, the child of his or her civil union partner, children under a court appointed guardianship. We treat a child as legally adopted from the time the child is placed in the home for purpose of adoption. We treat such a child this way whether or not a final adoption order is ever issued. At Our discretion, We can require proof that a person meets the definition of a Dependent. DEPENDENT'S ELIGIBILITY DATE. The later of: a) the Employee's Eligibility Date; or b) the date the person first becomes a Dependent.
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DEVELOPMENTAL DISABILITY or DEVELOPMENTALLY DISABLED. A severe, chronic disability that: a) is attributable to a mental or physical impairment or a combination of mental and physical
impairments; b) is manifested before the Member:
1. attains age 22 for purposes of the Diagnosis and Treatment of Autism and Other Developmental Disabilities provision; or
2. attains age 26 for all other provisions; c) is likely to continue indefinitely; d) results in substantial functional limitations in three or more of the following areas of major life
activity: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency;
e) reflects the Member’s need for a combination and sequence of special interdisciplinary or generic care, treatment or other services which are of lifelong or of extended duration and are individually planned and coordinated. Developmental disability includes but is not limited to severe disabilities attributable to mental retardation, autism, cerebral palsy, epilepsy, spina-bifida and other neurological impairments where the above criteria are met.
DIAGNOSTIC SERVICES. Procedures ordered by a recognized Provider because of specific symptoms to diagnose a specific condition or disease. Some examples include, but are not limited to: a) radiology, ultrasound, and nuclear medicine; b) laboratory and pathology; and c) EKG's, EEG's, and other electronic diagnostic tests. DISCRETION / DETERMINATION / DETERMINE. Our sole right to make a decision or determination. The decision will be applied in a reasonable and non-discriminatory manner. DURABLE MEDICAL EQUIPMENT. Equipment We Determine to be: a) designed and able to withstand repeated use; b) used primarily and customarily for a medical purpose; c) is generally not useful to a Member in the absence of an Illness or Injury; and d) suitable for use in the home. Durable Medical Equipment includes, but is not limited to, apnea monitors, breathing equipment, hospital-type beds, walkers, and wheelchairs as well as hearing aids which are covered through age 15. Items such as walkers, wheelchairs and hearing aids are examples of durable medical equipment that are also habilitative devices. Among other things, Durable Medical Equipment does not include: adjustments made to vehicles, air conditioners, air purifiers, humidifiers, dehumidifiers, elevators, ramps, stair glides, Emergency Alert equipment, handrails, heat appliances, improvements made to a Member's home or place of business, waterbeds, whirlpool baths, exercise and massage equipment. EFFECTIVE DATE. The date on which coverage begins under the Contract for the Contractholder, or the date coverage begins under the Contract for a Member, as the context in which the term is used suggests.
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EMERGENCY. A medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of Substance Abuse such that a prudent layperson, who possesses an average knowledge of health and medicine, could expect the absence of immediate medical attention to result in: placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. With respect to a pregnant woman who is having contractions, an Emergency exists where: there is inadequate time to effect a safe transfer to another Hospital before delivery; or the transfer may pose a threat to the health or safety of the woman or unborn child. EMPLOYEE. A Full-Time bona-fide Employee (25 hours per week) of the Contractholder. Employees who work on a temporary or substitute basis or who are participating in an employee welfare arrangement established pursuant to a collective bargaining agreement are not considered to be Employees for the purpose of the Contract. Pursuant to 26 USC 4980H, partners, proprietors and independent contractors are not employees of the Policyholder. EMPLOYEE OPEN ENROLLMENT PERIOD. The 30-day period each year designated by the Contractholder during which: a) Employees and Dependents who are eligible under the Contract but who are Late Enrollees
may enroll for coverage under the Contract; and b) Employees and Dependents who are covered under Contract may elect coverage under a
different policy, if any, offered by the Contractholder. EMPLOYEE'S ELIGIBILITY DATE. a) the date of employment; b) the day after any applicable waiting period ends; or c) the day after any applicable Orientation Period ends. EMPLOYER. The Contractholder as stated on the first page of the Contract. EMPLOYER OPEN ENROLLMENT PERIOD. The period from November 15 through December 15 each year beginning in 2014. ENROLLMENT DATE. With respect to a Member, the Effective Date or, if earlier, the first day of any applicable waiting period. If an Employee changes plans or if the Employer transfers coverage to another carrier, the Member’s Enrollment Date does not change. EXPERIMENTAL or INVESTIGATIONAL. Services or supplies which We Determine are: a) not of proven benefit for the particular diagnosis or treatment of a Member's particular
condition; or b) not generally recognized by the medical community as effective or appropriate for the
particular diagnosis or treatment of a Member's particular condition; or c) provided or performed in special settings for research purposes or under a controlled
environment or clinical protocol.
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Unless otherwise required by law with respect to drugs which have been prescribed for treatment for which the drug has not been approved by the United States Food and Drug Administration (FDA), We will not cover any services or supplies, including treatment, procedures, drugs, biological products or medical devices or any hospitalizations in connection with Experimental or Investigational services or supplies. We will also not cover any technology or any hospitalization in connection with such technology if such technology is obsolete or ineffective and is not used generally by the medical community for the particular diagnosis or treatment of a Member's particular condition. Governmental approval of a technology is not necessarily sufficient to render it of proven benefit or appropriate or effective for a particular diagnosis or treatment of a Member's particular condition, as explained below. We will apply the following five criteria in Determining whether services or supplies are Experimental or Investigational: 1. Any medical device, drug, or biological product must have received final approval to
market by the FDA for the particular diagnosis or condition. Any other approval granted as an interim step in the FDA regulatory process, e.g., an Investigational Device Exemption or an Investigational New Drug Exemption, is not sufficient. Once FDA approval has been granted for a particular diagnosis or condition, use of the medical device, drug or biological product for another diagnosis or condition will require that one or more of the following established reference compendia:
I. The American Hospital Formulary Service Drug Information; or II. The United States Pharmacopeia Drug Information.
recognize the usage as appropriate medical treatment. As an alternative to such recognition in one or more of the compendia, the usage of the drug will be recognized as appropriate if it is recommended by a clinical study or recommended by a review article in a major peer-reviewed professional journal. A medical device, drug, or biological product that meets the above tests will not be considered Experimental or Investigational. In any event, any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed will be considered Experimental or Investigational.
2. Conclusive evidence from the published peer-reviewed medical literature must exist that
the technology has a definite positive effect on health outcomes; such evidence must include well-designed investigations that have been reproduced by nonaffiliated authoritative sources, with measurable results, backed up by the positive endorsements of national medical bodies or panels regarding scientific efficacy and rationale;
3. Demonstrated evidence as reflected in the published peer-reviewed medical literature
must exist that over time the technology leads to improvement in health outcomes, i.e., the beneficial effects outweigh any harmful effects;
4. Proof as reflected in the published peer-reviewed medical literature must exist that the
technology is at least as effective in improving health outcomes as established
11
technology, or is usable in appropriate clinical contexts in which established technology is not employable; and
5. Proof as reflected in the published peer-reviewed medical literature must exist that
improvements in health outcomes, as defined in paragraph 3, is possible in standard conditions of medical practice, outside clinical investigatory settings.
EXTENDED CARE CENTER. See Skilled Nursing Facility. FACILITY. A place which: a) is properly licensed, certified, or accredited to provide health care under the laws of the state
in which it operates; and b) provides health care services which are within the scope of its license, certificate or
accreditation. FULL-TIME. A normal work week of 25 or more hours. Work must be at the Contractholder's regular place of business or at another place to which an Employee must travel to perform his or her regular duties for his or her full and normal work hours. GOVERNMENT HOSPITAL. A Hospital operated by a government or any of its subdivisions or agencies, including, but not limited to, a Federal, military, state, county or city Hospital. GROUP HEALTH PLAN. An employee welfare benefit plan, as defined in Title I of section 3 of Pub.L.93-406, the “Employee Retirement Income Security Act of 1974” (ERISA) (29 U.S.C. § 1002(1)) to the extent that the plan provides medical care and includes items and services paid for as medical care to employees or their dependents directly or through insurance, reimbursement or otherwise. HEALTH BENEFITS PLAN. Any hospital and medical expense insurance policy or certificate; health, hospital, or medical service corporation contract or certificate; or health maintenance organization subscriber contract or certificate delivered or issued for delivery in New Jersey by any carrier to a Small Employer group pursuant to section 3 of P.L. 1992. c. 162 (C. 17B: 27A-19) or any other similar contract, policy, or plan issued to a Small Employer, not explicitly excluded from the definition of a health benefits plan. Health Benefits Plan does not include one or more, or any combination of the following: coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers’ compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Health Benefits Plans shall not include the following benefits if they are provided under a separate policy, certificate or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long term care, nursing home care, home health care, community based care, or any combination thereof; and such other similar, limited benefits as are specified in federal regulations. Health Benefits Plan shall not include hospital confinement indemnity coverage if the benefits are provided under a separate policy, certificate or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group Health Benefits Plan maintained by the same Plan Sponsor, and those benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an
12
event under any Group Health Plan maintained by the same Plan Sponsor. Health Benefits Plan shall not include the following if it is offered as a separate policy, certificate or contract of insurance: Medicare supplemental health insurance as defined under section 1882(g)(1) of the federal Social Security Act; and coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code; and similar supplemental coverage provided to coverage under a Group Health plan. HEALTH STATUS-RELATED FACTOR. Any of the following factors: health status; medical condition, including both physical and mental Illness; claims experience; receipt of health care; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; and disability. HOME HEALTH AGENCY. A Provider which provides Skilled Nursing Care for Ill or Injured people in their home under a home health care program designed to eliminate Hospital stays. It must be licensed by the state in which it operates, or it must be certified to participate in Medicare as a Home Health Agency. HOSPICE. A Provider which provides palliative and supportive care for terminally Ill or terminally Injured people. It must carry out its stated purpose under all relevant state and local laws, and it must either: a) be approved for its stated purpose by Medicare; or b) be accredited for its stated purpose by the Joint Commission, the Community Health
Accreditation Program or the Accreditation Commission for Health Care. HOSPITAL. A Facility which mainly provides Inpatient care for Ill or Injured people. It must carry out its stated purpose under all relevant state and local laws, and it must either: a) be accredited as a Hospital by the Joint Commission, or b) be approved as a Hospital by Medicare. Among other things, a Hospital is not a convalescent, rest or nursing home or Facility, or a Facility, or part of it, which mainly provides Custodial Care, educational care or rehabilitative care. A Facility for the aged or substance abusers is not a Hospital. ILLNESS or ILL. A sickness or disease suffered by a Member or a description of a Member suffering from a sickness or a disease. Illness includes Mental Illness. INITIAL DEPENDENT. Those eligible Dependents an Employee has at the time he or she first becomes eligible for Employee coverage. If at the time the Employee does not have any eligible Dependents, but later acquires them, the first eligible Dependents he or she acquires are his or her Initial Dependents. INJURY or INJURED. Damage to a Member's body, and all complications arising from that damage or a description of a Member suffering from such damage. INPATIENT. Member if physically confined as a registered bed patient in a Hospital or other recognized health care Facility; or services and supplies provided in such a setting. JOINT COMMISSION. The Joint Commission on the Accreditation of Health Care Organizations.
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LATE ENROLLEE. An eligible Employee or Dependent who requests enrollment under the Contract more than 30 days after first becoming eligible. However, an eligible Employee or Dependent will not be considered a Late Enrollee under certain circumstances. See the Employee Coverage and Dependent Coverage subsections of the Eligibility section of the Contract. MEDICALLY NECESSARY AND APPROPRIATE. Services or supplies provided by a recognized health care Provider that We Determine to be: a) necessary for the symptoms and diagnosis or treatment of the condition, Illness or Injury; b) provided for the diagnosis or the direct care and treatment of the condition, Illness or Injury; c) in accordance with generally accepted medical practice; d) not for a Member's convenience; e) the most appropriate level of medical care that a Member needs; and f) furnished within the framework of generally accepted methods of medical management
currently used in the United States. In the instance of an Emergency, the fact that a Non-Network Provider prescribes, orders, recommends or approves the care, the level of care, or the length of time care is to be received, does not make the services Medically Necessary and Appropriate. MEDICAID. The health care program for the needy provided by Title XIX of the United States Social Security Act, as amended from time to time. MEDICARE. Parts A and B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time. MEMBER. An eligible person who is covered under the Contract (includes Covered Employee and covered Dependents, if any). MENTAL HEALTH CENTER. A Facility that mainly provides treatment for people with Mental Illness. It will be considered such a place if it carries out its stated purpose under all relevant state and local laws, and it is either: a) accredited for its stated purpose by the Joint Commission; b) approved for its stated purpose by Medicare or c) accredited or licensed by the State of New Jersey to provide mental health services. MENTAL ILLNESS. A behavioral, psychological or biological dysfunction. Mental illness includes a biologically-based mental illness as well as a mental illness that is not biologically-based. With respect to mental illness that is biologically based, mental illness means a condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism. The current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association may be consulted to identify conditions that are considered mental illness.
14
NETWORK PROVIDER. A Provider which has an agreement directly or indirectly with Us to provide Covered Services or Supplies. The Employee will have access to up-to date lists of Network Providers. NEWLY ACQUIRED DEPENDENT. An eligible Dependent an Employee acquires after he or she already has coverage in force for Initial Dependents. NON-COVERED SERVICES. Services or supplies which are not included within Our definition of Covered Services or Supplies, are included in the list of Non-Covered Services and Supplies, or which exceed any of the limitations shown in the Contract. NON- NETWORK PROVIDER. A Provider which is not a Network Provider. NURSE. A registered nurse or licensed practical nurse, including a nursing specialist such as a nurse mid-wife or nurse anesthetist, who: a) is properly licensed or certified to provide medical care under the laws of the state where the
nurse practices; and b) provides medical services which are within the scope of the nurse's license or certificate. ORIENTATION PERIOD. A period of no longer than one month during which the employer and employee determine whether the employment situation is satisfactory for each party and any necessary orientation and training processes commence. As used in this definition, one month is determined by adding one calendar month and subtracting one calendar day, measured from an Employee’s start date in a position that is otherwise eligible for coverage. Refer to 26 C.F.R. 54.9815-2708(c)(iii). ORTHOTIC APPLIANCE. A brace or support but does not include fabric and elastic supports, corsets, arch supports, trusses, elastic hose, canes, crutches, cervical collars, dental appliances or other similar devices carried in stock and sold by drug stores, department stores, corset shops or surgical supply facilities. OUTPATIENT. Member, if not confined as a registered bed patient in a Hospital or recognized health care Facility and not an Inpatient; or services and supplies provided in such Outpatient settings. PERIOD OF CONFINEMENT. Consecutive days of Inpatient services provided to an Inpatient, or successive Inpatient confinements due to the same or related causes, when discharge and re-admission to a recognized Facility occurs within 90 days or less. We Determine if the cause(s) of the confinements are the same or related. PLAN SPONSOR. Has the meaning given that term under Title I, section 3 of Pub.L.93-406, the ERISA (29 U.S.C. § 1002(16)(B)). That is: a) the Small Employer in the case of an employee benefit plan established or maintained by a single employer; b) the employee organization in the case of a plan established or maintained by an employee organization; or
15
c) in the case of a plan established or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, the association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the plan. PLAN YEAR. The year that is designated as the plan year in the plan document of a Group Health Plan, except if the plan document does not designate a plan year or if there is no plan document, the Plan Year is a Calendar Year. PRACTITIONER. A medical practitioner who: a) is properly licensed or certified to provide medical care under the laws of the state where the
practitioner practices; and b) provides medical services which are within the scope of the practitioner's license or
certificate. For purposes of Applied Behavior Analysis as included in the Diagnosis and Treatment of Autism and Other Developmental Disabilities provision, Practitioner also means a person who is credentialed by the national Behavior Analyst Certification Board as either a Board Certified Behavior Analyst – Doctoral or as a Board Certified Behavior Analyst. PRE-APPROVAL or PRE-APPROVED. Specific direction or instruction from a Network Practitioner or from Us in conformance with Our policies and procedures that authorizes a Member to use a Provider for health care services or supplies. For more information regarding the services for which We require Pre-Approval, consult the website at www.amerihealthnj.com. PRESCRIPTION DRUGS. Drugs, biologicals and compound prescriptions which are sold only by prescription and which are required to show on the manufacturer's label the words: "Caution - Federal Law Prohibits Dispensing Without a Prescription" or other drugs and devices as Determined by Us, such as insulin. But We only cover drugs which are: a) approved for treatment of the Member's Illness or Injury by the Food and Drug Administration; b) approved by the Food and Drug Administration for the treatment of a particular diagnosis or condition other than the Member's and recognized as appropriate medical treatment for the Member's diagnosis or condition in one or more of the following established reference compendia:
The American Hospital Formulary Service Drug Information;
The United States Pharmacopeia Drug Information; or c) recommended by a clinical study or recommended by a review article in a major peer-reviewed professional journal. Coverage for the above drugs also includes Medically Necessary and Appropriate services associated with the administration of the drugs. In no event will We pay for: a) drugs labeled: "Caution - Limited by Federal Law to Investigational Use"; or b) any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed. PREVENTIVE CARE. As used in this Contract preventive care means: a) Evidence based items or services that are rated “A” or “B” in the current recommendations
of the United States Preventive Services task Force with respect to the Member;
16
b) Immunizations for routine use for Members of all ages as recommended by the Advisory Committee on Immunization Practices of the Centers of Disease Control and Prevention with respect to the Member;
c) Evidence–informed preventive care and screenings for Members who are infants, children and adolescents, as included in the comprehensive guidelines supported by the Health Resources and Services Administration;
d) Evidence–informed preventive care and screenings for female Members as included in the comprehensive guidelines supported by the Health Resources and Services Administration; and
e) Any other evidence-based or evidence-informed items as determined by federal and/or state law.
Examples of preventive care include, but are not limited to: routine physical examinations, including related laboratory tests and x-rays, immunizations and vaccines, well baby care, pap smears, mammography, screening tests, bone density tests, colorectal cancer screening, and Nicotine Dependence Treatment. PRIMARY CARE PHYSICIAN (PCP). A Network Provider who is a doctor specializing in family practice, general practice, internal medicine, obstetrics/gynecology (for pre and post-natal care, birth and treatment of the diseases and hygiene of females, or pediatrics who supervises, coordinates, arranges and provides initial care and basic medical services to a Member; initiates a Member's Referral for Specialist Services; and is responsible for maintaining continuity of patient care. PRIVATE DUTY NURSING. Skilled Nursing Care for Covered Persons who require individualized continuous Skilled Nursing Care provided by a registered nurse or a licensed practical nurse. PROSTHETIC APPLIANCE. Any artificial device that is not surgically implanted that is used to replace a missing limb, appendage or any other external human body part including devices such as artificial limbs, hands, fingers, feet and toes, but excluding dental appliances and largely cosmetic devices such as artificial breasts, eyelashes, wigs and other devices which could not by their use have a significantly detrimental impact upon the musculoskeletal functions of the body. PROVIDER. A recognized Facility or Practitioner of health care. REFERRAL. Specific direction or instruction from a Member's Primary Care Physician in conformance with our policies and procedures that direct a Member to a Facility or Practitioner for health care. REHABILITATION CENTER. A Facility which mainly provides therapeutic and restorative services to Ill or Injured people. It must carry out its stated purpose under all relevant state and local laws, and it must either: a) be accredited for its stated purpose by either the Joint Commission or the Commission on
Accreditation for Rehabilitation Facilities; or b) be approved for its stated purpose by Medicare. In some places a Rehabilitation Center is called a “rehabilitation hospital.”
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ROUTINE FOOT CARE. The cutting, debridement, trimming, reduction, removal or other care of corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, dystrophic nails, excrescences, helomas, hyperkeratosis, hypertrophic nails, non-infected ingrown nails, deratomas, keratosis, onychauxis, onychocryptosis, tylomas or symptomatic complaints of the feet. Routine Foot Care also includes orthopedic shoes, and supportive devices for the foot. SERVICE AREA. A geographic area We define by county. SKILLED NURSING CARE. Services which are more intensive than Custodial Care, are provided by a registered nurse or licensed practical nurse ,and require the technical skills and professional training of a registered nurse or licensed practical nurse SKILLED NURSING FACILITY. A Facility which mainly provides full-time Skilled Nursing Care for Ill or Injured people who do not need to be in a Hospital. It must carry out its stated purpose under all relevant state and local laws, and it must either: a) be accredited for its stated purpose by the Joint Commission; or b) be approved for its stated purpose by Medicare. SMALL EMPLOYER. Means:
a) In connection with a Group Health Plan with respect to a Calendar Year and a Plan Year, any person, firm, corporation, partnership, or political subdivision that is actively engaged in business that employed an average of at least one but not more than 50 eligible Employees on business days during the preceding Calendar Year and who employs at least one eligible Employee on the first day of the Plan Year. All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. In the case of an employer that was not in existence during the preceding Calendar Year, the determination of whether the employer is a small or large employer shall be based on the average number of eligible Employees that it is expected that the employer will employ on business days in the current Calendar Year; OR
b) in connection with a Group Health Plan with respect to a Calendar Year and a Plan
year, an employer who employed an average of at least 1 but not more than 50 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the Plan Year.
All persons treated as a single employer under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as one employer. In the case of an Employer which was not in existence throughout the preceding Calendar Year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such Employer will employ on business days in the current Calendar Year. The following calculation must be used to determine if an employer employs at least 1 but not more than 50 employees. For purposes of this calculation: a) Employees working 30 or more hours per week are full-time employees and each full-
time Employee counts as 1;
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b) Employees working fewer than 30 hours per week are part-time and counted as the sum of the hours each part-time Employee works per week multiplied by 4 and the product divided by 120 and rounded down to the nearest whole number.
Add the number of full-time Employees to the number that results from the part-time employee calculation. If the sum is at least 1 but not more than 50 the employer employs at least 1 but not more than 50 Employees. SPECIALIST DOCTOR. A doctor who provides medical care in any generally accepted medical or surgical specialty or sub-specialty. SPECIALIST SERVICES. Medical care in specialties other than family practice, general practice, internal medicine or pediatrics or obstetrics/gynecology (for routine pre and post-natal care, birth and treatment of the diseases and hygiene of females). SPECIAL ENROLLMENT PERIOD. A period of time that is no less than 30 days or 60 days, as applicable, following the date of a Triggering Event during which: a) Late Enrollees are permitted to enroll under the Contractholder’s Policy; and b) Covered Employees and Dependents who already have coverage are permitted to replace
current coverage with coverage under a different policy, if any, offered by the Contractholder.
SPECIALTY PHARMACETICALS. Oral or injectable drugs that have unique production, administration or distribution requirements. They require specialized patient education prior to use and ongoing patient assistance while under treatment. These Prescription Drugs must be dispensed through specialty pharmaceutical providers. Examples of Prescription Drugs that are considered Specialty Pharmaceuticals include some orally administered anti-cancer Prescription Drugs and those used to treat the following conditions: Crohn’s Disease; Infertility; Hemophilia; Growth Hormone Deficiency; RSV; Cystic Fibrosis; Multiple Sclerosis; Hepatitis C; Rheumatoid Arthritis; and Gaucher’s Disease. AmeriHealth will provide a complete list of Specialty Phamaceuticals. The list is also available on AmeriHealth’s website. SUBSTANCE ABUSE. Abuse of or addiction to drugs or alcohol. SUBSTANCE ABUSE CENTER. A Facility that mainly provides treatment for people with Substance Abuse problems. It must carry out its stated purpose under all relevant state and local laws, and it must either: a) be accredited for its stated purpose by the Joint Commission; or b) be approved for its stated purpose by Medicare. SUPPLEMENTAL LIMITED BENEFIT INSURANCE. Insurance that is provided in addition to a Health Benefits Plan on an indemnity non-expense incurred basis. SURGERY. a) The performance of generally accepted operative and cutting procedures, including surgical
diagnostic procedures, specialized instrumentations, endoscopic examinations, and other procedures;
b) the correction of fractures and dislocations;
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c) pre-operative and post-operative care; d) any of the procedures designated by the Current Procedural Terminology Codes as surgery. THERAPEUTIC MANIPULATION. Treatment of the articulations of the spine and musculoskeletal structures for the purpose of relieving certain abnormal clinical conditions resulting from the impingement upon associated nerves causing discomfort. Some examples are manipulation or adjustment of the spine, hot or cold packs, electrical muscle stimulation, diathermy, skeletal adjustments, massage, adjunctive, ultra-sound, doppler, whirlpool , hydrotherapy or other treatment of similar nature. TOTAL DISABILITY OR TOTALLY DISABLED. Except as otherwise specified in the Contract, an Employee who, due to Illness or Injury, cannot perform any duty of his or her occupation or any occupation for which he or she is, or may be, suited by education, training and experience, and is not, in fact, engaged in any occupation for wage or profit. A Dependent is totally disabled if he or she cannot engage in the normal activities of a person in good health and of like age and sex. The Employee or Dependent must be under the regular care of a Practitioner. TRIGGERING EVENT. The following dates: a) The date an Employee or Dependent loses eligibility for minimum essential coverage
including a loss of coverage resulting from the decertification of a qualified health plan by the marketplace. A loss of coverage resulting from nonpayment of premium, fraud or misrepresentation of material fact shall not be a Triggering Event.
b) The date an Employee acquires a Dependent or becomes a Dependent due to marriage, birth, adoption, placement for adoption, or placement in foster care.
c) The date an Employee’s enrollment or non-enrollment in a qualified health plan is the result of error, misrepresentation or inaction by the federal government.
d) The date an Employee or eligible Dependent demonstrates to the marketplace that the qualified health plan in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.
e) The date the Employee or Dependent gains access to new qualified health plans as a result of a permanent move.
f) The date the Employee or Dependent loses eligibility for Medicaid or NJ FamilyCare. g) The date the Employee or Dependent becomes eligible for assistance under a Medicaid or
NJ FamilyCare plan. h) The date of a court order that requires coverage for a Dependent. URGENT CARE. Care for a non-life threatening condition that requires care by a Provider within 24 hours. WAITING PERIOD. With respect to a Group Health Plan and an individual who is a potential participant or beneficiary in the Group Health Plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the Group Health Plan. The Waiting Period begins on the first day following the end of the Orientation Period, if any. WE, US, OUR. AmeriHealth HMO, Inc. or AmeriHealth. YOU, YOUR, YOURS. An Employee who is covered under the Contract.
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ELIGIBILITY EMPLOYEE COVERAGE Eligible Employees Subject to the Conditions of Eligibility set forth below, and to all of the other conditions of the Contract, all of the Contractholder's Employees who are in an eligible class and who reside in the Service Area will be eligible if the Employees are Full-Time Employees. Conditions of Eligibility Full-Time Requirement We will not cover an Employee unless the Employee is a Full-Time Employee. Enrollment Requirement We will not cover the Employee until the Employee enrolls and agrees to make the required payments, if any. If the Employee does this within 30 days of the Employee's Eligibility Date, coverage will start on the Employee's Eligibility Date. If the Employee enrolls and agrees to make the required payments, if any: a) more than 30 days after the Employee's Eligibility Date; or b) after the Employee previously had coverage which ended because the Employee failed to
make a required payment, We will consider the Employee to be a Late Enrollee. Late enrollees may request enrollment during the Employee Open Enrollment Period. Coverage will take effect on the Contractholder’s Contract Anniversary date following enrollment. Special Enrollment Rules When an Employee initially waives coverage under the Contract, the Plan Sponsor should notify the Employee of the requirement for the Employee to make a statement that waiver was because he or she was covered under another group plan, if such other coverage was in fact the reason for the waiver, and the consequences of that requirement. If an Employee initially waived coverage under the Contract and the Employee stated at that time that such waiver was because he or she was covered under another group plan, and Employee now elects to enroll under the Contract, We will not consider the Employee and his or her Dependents to be Late Enrollees, and will assign an effective date consistent with the provisions that follow provided the coverage under the other plan ends due to one of the following events: a) termination of employment or eligibility; b) reduction in the number of hours of employment; c) involuntary termination; d) divorce or legal separation or dissolution of the civil union; e) death of the Employee's spouse; f) termination of the Employer’s contribution toward coverage; or g) termination of the other plan's coverage.
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But, the Employee must enroll under the Contract within 90 days of the date that any of the events described above occur. Coverage will take effect as of the date the applicable event occurs. If an Employee initially waived coverage under the Contract because he or she had coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation provision and the Employee requests coverage under the Contract within 30 days of the date the COBRA continuation ended, We will not consider the Employee to be a Late Enrollee. Coverage will take effect as of the date the COBRA continuation ended. In addition, an Employee and any Dependents will not be considered Late Enrollees if the Employee is employed by an employer which offers multiple Health Benefits Plans and the Employee elects a different plan during the open enrollment period. Further, an Employee and his or her Dependent spouse, if any, will not be considered Late Enrollees because the Employee initially waived coverage under the Contract for himself or herself and any then existing Dependents provided the Employee enrolls to cover himself or herself and his or her existing Dependent spouse, if any, under the Contract within 30 days of the marriage, birth, adoption or placement for adoption of a Newly Acquired Dependent. If an Employee or any Dependent experiences a Triggering Event the Employee and Dependents may elect to enroll during the Special Enrollment Period that follows the Triggering Event. The election period is generally the 30 day period following the Triggering Event. If the Triggering Event is losing or gaining eligibility for Medicaid or NJ Family Care, the election period is 60 days. If the Triggering Event is marriage, birth, adoption, placement for adoption, or placement in foster care, coverage will take effect as of the date of the marriage, birth, adoption, placement for adoption, or placement in foster care. For all other Triggering Events, coverage will take effect as of the first of the month following receipt of the enrollment form. The Orientation Period and Waiting Period This Policy has an Orientation Period and the following Waiting Periods: Employees in an eligible class on the Effective Date, who have completed the Orientation Period and who have completed at least 90 days of Full-Time service with the Policyholder by that date, are covered under this Policy from the Effective Date. Employees in an eligible class on the Effective Date, who are completing or have completed the Orientation Period but who have not completed at least 90 days of Full-Time service with the Policyholder by that date, are eligible for coverage under this Policy from the day after Employees complete 90 days of Full-Time service. Employees who enter an eligible class after the Effective Date who have completed the Orientation Period are eligible for coverage under this Policy from the day after Employees complete 90 days of Full-Time service with the Policyholder. Multiple Employment If an Employee works for both the Contractholder and a covered Affiliated Company, or for more than one covered Affiliated Company, We will treat the Employee as if only one entity employs
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But, the Employee. And such an Employee will not have multiple coverage under the Contract. But, if the Contract uses the amount of an Employee’s earnings or number of work hours to determine class, or for any other reason, such Employee’s earnings or number of work hours will be figured as the sum of his or her earnings or number of work hours from all Affiliated Companies. When Employee Coverage Starts An Employee must be working his or her regular number of hours, on the date his or her coverage is scheduled to start. And he or she must have met all the conditions of eligibility which apply to him or her. The Employee must elect to enroll and agree to make the required payments if any, within 30 days of the Employee's Eligibility Date. If he or she does this within 30 days of the Employee's Eligibility Date, his or her coverage is scheduled to start on the Employee's Eligibility Date. Such Employee's Eligibility Date is the Effective Date of an Employee's coverage. If the Employee does this more than 30 days after the Employee’s Eligibility Date, We will consider the Employee a Late Enrollee. The Employee may request enrollment during the Employee Open Enrollment period. Coverage will take effect on the Policyholder’s Anniversary date following enrollment. Exception: If the coverage under the Contract is richer than the coverage under the Contractholder’s old plan, the Contract will provide coverage for services and supplies related to the disabling condition. The Contract will coordinate with the Contractholder’s old plan, with the Contract providing secondary coverage, as described in the Coordination of Benefits and Services provision. When Employee Coverage Ends An Employee's coverage under the Contract will end on the first of the following dates: a) the date an Employee ceases to be a Full-Time Employee for any reason. Such reasons
include death, retirement, lay-off, leave of absence, and the end of employment. b) the date an Employee stops being an eligible Employee under the Contract. c) the date the Contract ends, or is discontinued for a class of Employees to which the
Employee belongs. d) the date for which required payments are not made for the Employee, subject to the
Payment of Premiums - Grace Period section. e) the date an Employee no longer lives, works or resides in the Service Area.
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DEPENDENT COVERAGE Contractholder Election A Contractholder that elects to make Dependent coverage available under the Contract may choose to make coverage available for all eligible Dependents, as defined below or may choose to make coverage available only for Dependent Children. If the Contractholder limits Dependent coverage to Dependent Children, the term “Dependent” as used in this Contract is limited to Dependent Children. Eligible Dependents for Dependent Health Benefits Except as stated below, Your eligible Dependents are:
a) Your legal spouse which shall include a civil union partner pursuant to P.L. 2006, c. 103 as well as same sex relationships legally recognized in other jurisdictions when such relationships provide substantially all of the rights and benefits of marriage; except that legal spouse shall be limited to spouses of a marriage as marriage is defined in Federal law with respect to:
the provisions of the Policy regarding continuation rights required by the Federal Consolidated Omnibus Reconciliation Act of 1986 (COBRA), Pub. L. 99-272, as subsequently amended); and
The provisions of this Contract regarding Medicare Eligibility by Reason of Age and Medicare Eligibility by Reason of Disability.
b) Your Dependent children who are under age 26. Exception: Any dependent who does not reside in the Service Area is not an eligible Dependent. Note: If the Contractholder elects to limit coverage to Dependent Children, the term Dependent excludes a legal spouse. Adopted Children, Step-Children, Foster Children Your " Dependent children" include Your legally adopted children, Your step-children, Your foster children, the child of his or her civil union partner, and children under a court appointed guardianship. AmeriHealth will treat a child as legally adopted from the time the child is placed in the home for the purpose of adoption. AmeriHealth will treat such a child this way whether or not a final adoption order is ever issued. Incapacitated Children An Employee may have an unmarried child with a mental or physical handicap, or developmental disability, who is incapable of earning a living. Subject to all of the terms of this section and the plan, such a child may stay eligible for Dependent health benefits past the Contract's age limit for eligible Dependents. The child will stay eligible as long as the child is and remains unmarried and incapable of earning a living, if: a) the child's condition started before he or she reached the Contract's age limit;
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b) the child depends on the Employee for most of his or her support and maintenance; and c) the child became covered by the Contract or any other policy or contract before the child
reached the age limit and stayed continuously covered after reaching such limit. But, for the child to stay eligible, the Employee must send Us written proof that the child is handicapped or developmentally disabled and depends on the Employee for most of his or her support and maintenance. The Employee has 31 days from the date the child reaches the age limit to do this. We can ask for periodic proof that the child's condition continues. But, after two years, We cannot ask for this more than once a year. The child's coverage ends when the Employee's coverage does. Enrollment Requirement You must enroll Your eligible Dependents in order for them to be covered under the Contract. AmeriHealth considers an eligible Dependent to be a Late Enrollee, if You: a) enroll a Dependent and agrees to make the required payments more than 30 days after the
Dependent's Eligibility Date; b) in the case of a Newly Acquired Dependent, have other eligible Dependents whose
coverage previously ended because You failed to make the required contributions, or otherwise chose to end such coverage.
If Your dependent coverage ends for any reason, including failure to make the required payments, Your Dependents will be considered Late Enrollees when their coverage begins again. When an Employee initially waives coverage for a spouse and/or eligible Dependent children under the Contract, the Plan Sponsor should notify the Employee of the requirement for the Employee to make a statement that waiver was because the spouse and/or eligible Dependent children were covered under another group plan, if such other coverage was in fact the reason for the waiver, and the consequences of that requirement. If the Employee previously waived coverage for the Employee's spouse or eligible Dependent children under the Contract and stated at that time that such waiver was because they were covered under another group plan, and the Employee now elects to enroll them in the Contract, the Dependent will not be considered a Late Enrollee, provided the Dependent's coverage under the other plan ends due to one of the following events: a) termination of employment or eligibility; b) reduction in the number of hours of employment; c) involuntary termination; d) divorce or legal separation or dissolution of the civil union; e) death of the Employee's spouse; f) termination of the employer’s contribution toward coverage that was made by the employer
that offered the group plan under which the Dependent was covered; or g) termination of the other plan's coverage. But, the Employee's spouse or eligible Dependent children must be enrolled by the Employee within 90 days of the date that any of the events described above occur. Coverage will take effect as of the date the applicable event occurs.
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And, We will not consider an Employee's spouse or eligible Dependent children for which the Employee initially waived coverage under the Contract, to be a Late Enrollee, if: a) the Employee is under legal obligation to provide coverage due to a court order; and b) the Employee's spouse or eligible Dependent children are enrolled by the Employee within
30 days of the issuance of the court order. Coverage will take effect as of the date required pursuant to the court order. In addition, if an Employee initially waived coverage under the Contract for the Employee's spouse or eligible Dependent children because the spouse and/or Dependent children had coverage under a Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation provision and the Employee requests coverage for the spouse and/or Dependent children under the Contract within 30 days of the date the COBRA continuation ended, We will not consider the spouse and/or Dependent children to be Late Enrollees. Coverage will take effect as of the date the COBRA continuation ended. When Dependent Coverage Starts In order for an Employee's dependent coverage to begin the Employee must already be covered for Employee coverage or enroll for Employee and Dependent coverage at the same time. Subject to all of the terms of the Contract, the date an Employee's dependent coverage starts depends on when the Employee elects to enroll the Employee's Initial Dependents and agrees to make any required payments. If the Employee does this within 30 days of the Dependent's Eligibility Date, the Dependent's Coverage is scheduled to start on the later of: a) the Dependent's Eligibility Date, or b) the date the Employee becomes insured for Employee coverage. If the Employee does this more than 30 days after the Dependent's Eligibility Date, We will consider the Dependent a Late Enrollee. An Employee may elect to cover a Dependent who is a Late Enrollee during the Employee Open Enrollment Period. Coverage will take effect on the Contractholder’s Contract Anniversary date following enrollment. Once an Employee has dependent coverage for Initial Dependents, the Employee must notify Us of a Newly Acquired Dependent within the 30 days after the Newly Acquired Dependent's Eligibility Date. If the Employee does not, the Newly Acquired Dependent is a Late Enrollee. A Newly Acquired Dependent other than a newborn child or newly adopted child, including a child placed for adoption, will be covered from the later of: a) the date the Employee notifies Us and agrees to make any additional payments. If the Contractholder who purchased the Contract purchased it to replace a plan the Contractholder had with some other carrier, a Dependent who is Totally Disabled on the date the Contract takes effect will initially be eligible for limited coverage under the Contract if: a) the Dependent was validly covered under the Contractholder’s old plan on the date the
Contractholder’s old plan ended; and b) the Contract takes effect immediately upon termination of the prior plan. The coverage under the Contract will be limited to coverage for services or supplies for conditions other than the disabling condition. Such limited coverage under the Contract will end one year from the date the person’s coverage under the Contract begins. Coverage for
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services or supplies for the disabling condition will be provided as stated in an extended health benefits, or like provision, contained in the Contractholder’s old plan. Thereafter, coverage will not be limited as described in this provision, but will be subject to the terms and conditions of the Contract. Newborn Children We will cover an Employee's newborn child for 31 days from the date of birth without additional premium. Coverage may be continued beyond such 31 day period as stated below: a) If the Employee is already covered for Dependent child coverage on the date the child is
born, coverage automatically continues beyond the initial 31 days, provided the premium required for Dependent child coverage continues to be paid. The Employee must notify Us of the birth of the newborn child as soon as possible in order that We may properly provide coverage under the Contract.
b) If the Employee is not covered for Dependent child coverage on the date the child is born, the Employee must:
1) give written notice to enroll the newborn child; and 2) pay the premium required for Dependent child coverage within 31 days after the date of
birth. If the notice is not given and the premium is not paid within such 31-day period, the newborn child’s coverage will end at the end of such 31-day period. If the notice is given and the premium paid after that 31-day period, the child will be a Late Enrollee. When Dependent Coverage Ends: A Dependent's coverage under the Contract will end on the first of the following dates: a) the dateEmployee coverage ends; b) the date the Employee stops being a member of a class of Employees eligible for such
coverage; c) the date the Contract ends; d) the date Dependent coverage is dropped from the Contract for all Employees eligible for
such coverage; e) the date an Employee fails to pay any required part of the cost of Dependent coverage. It
ends on the last day of the period for which the Employee made the required payments, unless coverage ends earlier for other reasons.
f) at 12:01 a.m. on the last day of the calendar month following the date the Dependent stops being an eligible Dependent.
g) with respect to a Dependent spouse, the date the spouse moves his or her permanent residence outside the Service Area.
EXTENDED HEALTH BENEFITS If the Contract ends and a Member is Totally Disabled and under a Practitioner’s care, We will extend health benefits for that person under the Contract as explained below. This is done at no cost to the Member. We will only extend benefits for a Member due to the disabling condition. Any services and supplies must be provided before the extension ends. And what We cover is based on all the terms of the Contract.
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We do not cover services, supplies or charges due to other conditions. And, We do not cover services, supplies or charges incurred by other family members. The extension ends on the earliest of: a) the date the Total Disability ends; b) one year from the date the person’s coverage under the Contract ends; or c) the date the person has reached the payment limit, if any, for his or her disabling condition. The Employee must submit evidence to Us that he or she or his or her Dependent is Totally Disabled, if We request it. TERMINATION FOR CAUSE If any of the following conditions exist, We may give written notice to the Member that the person is no longer covered under the Contract: a) Untenable Relationship: After reasonable efforts, We and/or Network Providers are
unable to establish and maintain a satisfactory relationship with the Member or the Member fails to abide by our rules and regulations, or the Member acts in a manner which is verbally or physically abusive.
b) Misuse of Identification Card: The Member permits any other person who is not authorized by Us to use any identification card We issue to the Member.
c) Furnishing Incorrect or Incomplete Information: The Member furnishes material information that is either incorrect or incomplete in a statement made for the purpose of effecting coverage under the Contract. This condition is subject to the provisions of the Incontestability of the Contract section.
d) Nonpayment: The Member fails to pay any Copayment or Coinsurance or to make any reimbursement to Us required under the Contract.
e) Misconduct: The Member abuses the system, including but not limited to; theft, damage to Our Network Provider's property, forgery of drug prescriptions, and consistent failure to keep scheduled appointments.
f) Failure to Cooperate: The Member fails to assist Us in coordinating benefits as described in the Coordination of Benefits and Services Section.
If We give the Member such written notice: a) that person will cease to be a Member for the coverage under the Contract immediately if
termination is occurring due to Misuse of Identification Card (b above) or Misconduct (e above), otherwise, on the date 31 days after such written notice is given by Us; and
b) no benefits will be provided to the Member under the coverage after that date. Any action by Us under these provisions is subject to review in accordance with the Appeal Procedures We establish.
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MEMBER PROVISIONS THE ROLE OF A MEMBER'S PRIMARY CARE PHYSICIAN A Member's Primary Care Physician provides basic health maintenance services and coordinates a Member's overall health care. Anytime a Member needs medical care, the Member should contact his or her Primary Care Physician and identify himself or herself as a Member of this program. In an Emergency, a Member may go directly to the emergency room. If a Member does, then the Member must call his or her Primary Care Physician and Member Services within 48 hours. If a Member does not call within 48 hours, We will provide services only if We Determine that notice was given as soon as was reasonably possible. SELECTING OR CHANGING A PRIMARY CARE PHYSICIAN When an Employee first obtains this coverage, the Employee and each of the Employee's covered Dependents must select a Primary Care Physician. Members select a Primary Care Physician from Our Physician or Practitioners Directory; this choice is solely a Member's. However, We cannot guarantee the availability of a particular Practitioner. If the Primary Care Physician initially selected cannot accept additional patients, a Member will be notified and given an opportunity to make another Primary Care Physician selection. If a Member fails to select a Primary Care Physician , We will make a selection on behalf of the Member. After initially selecting a Primary Care Physician, Members can transfer to different Primary Care Physicians if the physician-patient relationship becomes unacceptable. The Member can select another Primary Care Physician from Our Physician or Practitioners Directory. For a discretionary change of PCP, the new PCP selection will take effect no more than 14 days following the date of the request. For a change necessitated by termination of the prior PCP from the Network, the new PCP selection will take effect immediately. NETWORK The Member will have access to given up-to date lists of Network Providers. Except in the case of Urgent Care or a medical Emergency, a Member must obtain Covered Services and Supplies from Network Providers to receive benefits under this Contract. Services and supplies obtained from Providers that are not Network Providers will generally not be covered. IDENTIFICATION CARD The Identification Card issued by Us to Members pursuant to the Contract is for identification purposes only. Possession of an Identification Card confers no right to services or benefits under the Contract, and misuse of such Identification Card constitutes grounds for termination of Member's coverage. If the Member who misuses the card is the Employee, coverage may be terminated for the Employee as well as any of the Employee's Dependents who are Members. To be eligible for services or benefits under the Contract, the holder of the card must be a Member on whose behalf all applicable premium charges under the Contract have been paid.
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Any person receiving services or benefits which he or she is not entitled to receive pursuant to the provisions of the Contract shall be charged for such services or benefits at prevailing rates. If any Member permits the use of his or her Identification Card by any other person, such card may be retained by Us, and all rights of such Member and his or her Dependents, if any, pursuant to the Contract shall be terminated immediately, subject to the Appeals Procedures. CONFIDENTIALITY Information contained in the medical records of Members and information received from physicians, surgeons, hospitals or other health professionals incident to the physician-patient relationship or hospital-patient relationship shall be kept confidential by Us; and except for use incident to bona fide medical research and education as may be permitted by law, or reasonably necessary in connection with the administration of the Contract or in the compiling of aggregate statistical data, or with respect to arbitration proceedings or litigation initiated by Member against Us, may not be disclosed without the Member's written consent, except as required or authorized by law. INABILITY TO PROVIDE NETWORK SERVICES AND SUPPLIES In the event that due to circumstances not within Our reasonable control, including but not limited to major disaster, epidemic, complete or partial destruction of facilities, riot, civil insurrection, disability of a significant part of Our Network Providers or entities with whom We have arranged for services under the Contract, or similar causes, the rendition of medical or hospital benefits or other services provided under the Contract is delayed or rendered impractical, We shall not have any liability or obligation on account of such delay or failure to provide services. We are required only to make a good faith effort to provide or arrange for the provision of services, taking into account the impact of the event. REFERRAL FORMS A Member can be Referred for Specialist Services by a Member's Primary Care Physician. Except in the case of an Emergency, a Member will not be eligible for any services provided by anyone other than a Member's Primary Care Physician (including but not limited to Specialist Services) if a Member has not been Referred by his or her Primary Care Physician. Referrals must be obtained prior to receiving services and supplies from any Practitioner other than the Member’s Primary Care Physician. NON-COMPLIANCE WITH MEDICALLY NECESSARY AND APPROPRIATE TREATMENT A Member has the right under New Jersey law to refuse procedures, medicines, or courses of treatment. A Member has the right to participate in decision-making regarding the Member's care. Further, a Member may, for personal, religious or cultural reasons disagree or not comply with procedures, medicines, or courses of treatment deemed Medically Necessary and Appropriate by a Network Practitioner. A Member who refuses procedures, medicines or courses of treatment has the right to seek a second opinion from another Network Practitioner. If such Network Practitioner(s) believe(s) that the recommended procedures, medicines, or courses of treatment are Medically Necessary and Appropriate, the Network Practitioner shall inform the Member of the consequences of not complying with the recommended procedures, medicines, or courses of treatment and seek to resolve the disagreement with the Member and or the Member's family or other person acting on the Member's behalf. If the Member refuses to comply with recommended procedures, medicines, or courses of treatment, We will notify the Member in writing that We will not provide further benefits or services for the particular condition
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or its consequences The Member's decision to reject Medically Necessary and Appropriate procedures, medicines, or courses of treatment is subject to the Appeals Procedure and We will continue to provide all benefits covered by the Contract during the pendency of the Appeals Procedure. We reserve the right to expedite the Appeals Procedure. If the Appeals Procedure results in a decision upholding the position of the Network Practitioner(s) and the dispute is unresolved, We will have no further responsibility to provide any of the benefits available under the Contract for treatment of such condition or its consequences unless the Member asks, in writing and within 7 days of being informed of the result of the Appeals Procedure, to terminate his or her coverage under the Contract. In such event, We will continue to provide all benefits covered by the Contract for 30 days or until the date of termination, whichever comes first, and We and the Network Practitioner will cooperate with the Member in facilitating a transfer of care. REFUSAL OF LIFE-SUSTAINING TREATMENT A Member has the right under New Jersey law to refuse life sustaining treatment. A Member who refuses life sustaining treatment remains eligible for all benefits including Home Health and Hospice benefits in accordance with the Contract. We will follow a Member's properly executed advance directive or other valid indication of refusal of life sustaining treatment. REPORTS AND RECORDS We are entitled to receive from any Provider of services to a Member, such information We deem is necessary to administer the Contract, subject to all applicable confidentiality requirements as defined in the Contract. By accepting coverage under the Contract, the Employee, for himself or herself, and for all Dependents covered hereunder, authorizes each and every Provider who renders services to the Member hereunder to disclose to Us all facts and information pertaining to the care, treatment and physical condition the Member and render reports pertaining to same to Us, upon request, and to permit copying of a Member's records by Us. MEDICAL NECESSITY Members will receive designated benefits under the Contract only when Medically Necessary and Appropriate. We may Determine whether any benefit provided under the Contract was Medically Necessary and Appropriate, and We have the option to select the appropriate Network Hospital to render services if hospitalization is necessary. Decisions as to what is Medically Necessary and Appropriate are subject to review by Our quality assessment committee or its physician designee. We will not, however, seek reimbursement from an eligible Member for the cost of any covered benefit provided under the Contract that is later Determined to have been medically unnecessary and inappropriate, when such service is rendered by a Primary Care Physician or a Provider referred in writing by the Primary Care Physician without notifying the Member that such benefit would not be covered under the Contract. LIMITATION ON SERVICES Except in cases of Emergency, services are available only from Network Providers. We shall have no liability or obligation whatsoever on account of any service or benefit sought or received by a Member from any Provider or other person, entity, institution or organization unless prior arrangements are made by Us. PROVIDER PAYMENT Different providers in Our Network have agreed to be paid in different ways by Us. A Member’s Provider may be paid each time he or she treats the Member (“fee for service”, or may be paid a set fee for each month for each Member whether or not the Member actually receives services
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(“capitation”), or may receive a salary. These payment methods may include financial incentive agreements to pay some providers more (“bonuses”) or less (“withholds”) based on many factors: Member satisfaction, quality of care, and control of costs and use of services among them. If a Member desires additional information about how Our Primary Care Physicians or any other Provider in Our Network are compensated, please call Us at (800) 877-9829 (TTY: 711) or write AmeriHealth Correspondence, P.O. Box 8128, Philadelphia, PA 19101-8128. The laws of the state of New Jersey, at N.J.S.A. 45:9-22.4 et seq., mandate that a physician, chiropractor or podiatrist who is permitted to make Referrals to other health care Providers in which he or she has a significant financial interest inform his or her patients of any significant financial interest he or she may have in a health care Provider or Facility when making a Referral to that health care Provider or Facility. If a Member wants more information about this the Member, the Member should contact his or her physician, chiropractor or podiatrist. If a Member believes he or she is not receiving the information to which the Member is entitled, contact the Division of Consumer Affairs in the New Jersey Department of Law and Public Safety at (973) 504-6200 (TTY: 711) OR (800) 242-5846 (TTY: 711). APPEAL PROCEDURE RESOLVING PROBLEMS (Complaint/Appeals) Member Complaint Process Complaints fall into one of two categories: Administrative Complaints and quality Complaints. Administrative Complaints include the following: coverage limitations, participating or non-participating Provider status, cost sharing requirements. Administrative Complaints follow the Internal Standard Appeals Process below. The HMO has a process for Members to express informal quality Complaints. To register a quality Complaint (as opposed to an Internal Appeal as discussed below), Members should call Customer Service at the telephone number on the back of their Identification Card or write to the HMO at the following address:
AmeriHealth NJ Appeals Unit 259 Prospect Plains Road, Bldg M Cranbury, NJ 08512 Phone: 1-877-585-5731 prompt #2 (TTY: 711) Fax: 609-662-2480
Most Member concerns are resolved informally at this level. However, if the HMO is unable to immediately resolve the Member Complaint, it will be investigated, and the Member will receive a response in writing within thirty (30) days.
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If the Member is dissatisfied with the resolution reached through the HMO’s Internal Appeal process, the Member may contact the Department of Banking and Insurance at the following address:
Consumer Protection Services Department of Banking and Insurance 20 West State Street, 9th floor P.O. Box 329 Trenton, NJ 08625-0329 Phone: 609-292-5316 (TTY: 711) Fax: 609-292-5865
Member Appeal Process Authorizing Someone To Represent You. At any time, a Member may choose a third party to be a representative in their Member Internal Appeal such as a Provider, lawyer, relative, friend, another individual, or a person who is part of an organization. The law states that the Member’s written authorization or consent is required in order for this third party, called an “authorized representative”, to pursue an Internal Appeal on the Member’s behalf. An authorized representative may make all decisions regarding the Internal Appeal, provide and obtain correspondence, and authorize the release of medical records and any other information related to an Appeal. In addition, if a Member chooses to authorize an Appeal representative, the Member has the right to limit their authority to release and receive medical records or other Appeal information in any other way identified by the Member. In order to authorize someone to be an authorized representative, the Member must complete valid authorization forms. The required forms are sent to adult Members or to the parents, guardians or other legal representatives of minor or incompetent Members who Appeal and indicate that they want an authorized representative. Authorization forms can be obtained by calling or writing to the address listed below:
AmeriHealth NJ Appeals Unit 259 Prospect Plains Road, Bldg M Cranbury, NJ 08512 Phone: 1-877-585-5731 prompt #2 (TTY: 711) Fax: 609-662-2480
Except in the case of an Internal Urgent/Expedited Appeal, the HMO must receive completed, valid authorization forms before an Appeal can be processed. (For information on Internal Urgent/Expedited Appeals, see the definition below.) A Member has the right to withdraw or rescind authorization of an authorized representative at any time during the process. If a Provider files an Internal Appeal on the Member’s behalf, the HMO will verify that the Provider is acting as the Member’s authorized representative with the Member’s permission by obtaining valid authorization forms. A Member who authorizes the filing of an Internal Appeal by a Provider cannot file a separate Internal Appeal.
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GENERAL INFORMATION ABOUT THE APPEALS PROCESS Advanced Notification. The HMO will not terminate or reduce an ongoing course of treatment without providing the Member or authorized representative with advance notice and the opportunity for advanced review. An Appeal may be filed within one hundred eighty (180) days of the receipt of a decision from the HMO stating an adverse benefit determination. At anytime during the Internal Appeal process, a Member may request the help of an HMO employee in preparing or presenting their Appeal; this assistance will be available at no charge. The HMO employee designated to assist the Member will not have participated in the previous decision for the issue in dispute and will not be a subordinate of the original reviewer. The Member or other authorized representative may request an Internal Appeal by calling or writing to the HMO, as defined in the letter notifying the Member of the decision or as follows:
AmeriHealth NJ Appeals Unit 259 Prospect Plains Road, Bldg M Cranbury, NJ 08512 Phone: 1-877-585-5731 prompt #2 (TTY: 711) Fax: 609-662-2480
Full and Fair Review. The Member or authorized representative is entitled to a full and fair review. Specifically, at all levels of Internal Appeal the Member or authorized representative may submit additional information pertaining to the case to the HMO. The Member or authorized representative may specify the remedy or corrective action being sought. At the Member’s request, the HMO will provide access to and copies of all relevant documents, records, and other information that are not confidential, proprietary, or privileged. The HMO will automatically provide the Member or authorized representative with any new or additional evidence considered, relied upon, or generated by the HMO in connection with the Appeal, which is used to formulate the rationale. Such evidence is provided as soon as possible and in advance of the date the final internal adverse benefit determination is issued. This information is provided to the Member or authorized representative at no charge. Types of Appeals. Following are the two types of Appeals and the issues they address: Administrative Appeal. A dispute or objection by a Member regarding the following: coverage limitations, participating or non-participating Provider status, cost sharing requirements, and rescission of coverage (except for failure to pay premiums or coverage contributions), that has not been resolved by the HMO. The Level I Administrative Appeal decision-maker is a Plan medical director or Physician designee. This individual has had no previous involvement with the case and is not a subordinate of anyone involved with a previous adverse determination. Level 1 and Level 2 Administrative Appeals are available and described below. A Level 2 Administrative Appeal determination is final. External Review is not available for Administrative Appeal issues. Medical Necessity Appeal. An Appeal by or on behalf of a Member that focuses on issues of Medical Necessity and requests the HMO to change its decision to deny or limit the provision of a Covered Service. Medical Necessity Appeals include Appeals of adverse benefit determinations based on the exclusions for Experimental/Investigational Services or cosmetic services. The standard Stage 1 Internal Appeal decision-maker is a Plan medical director who is a matched specialist or the decision-maker receives input from a consultant who is a matched
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specialist. A matched specialist or “same or similar specialty Physician” is a licensed Physician or Psychologist who is in the same or similar specialty as typically manages the care under review. The decision-maker has had no previous involvement in the case; is not a subordinate of the person who made the original determination, and holds an active unrestricted license to practice medicine. Stage 1 and Stage 2 Medical Necessity Appeals and External Review are available and described below. Urgent/Expedited Care. An Urgent/Expedited Appeal is any Appeal for medical care or treatment with respect to which the application of the time periods for making non-urgent determinations regarding urgent or emergent care, an admission, availability of care, continued stay and health care services for which the Member received Emergency Services but has not been discharged from a facility. Members with Urgent Care conditions or who are receiving an on-going course of treatment may proceed with an expedited External Review at the same time as the Internal Urgent/Expedited Appeals process. Appeal Decision Letter. If the Appeal is upheld, the letter states the reason(s) for the decision. If a benefit provision, internal rule, guideline, protocol, or other similar criterion is used in making the determination, the Member may request copies of this information at no charge. If the decision is to uphold the denial, there is an explanation of the scientific or clinical judgment for the determination. The letter also indicates the qualifications of the individual who decided the Appeal and their understanding of the nature of the Appeal. The letter will have instructions of the Appeal process, and, if applicable, any forms required to initiate a next level Appeal. The Member or authorized representative may request in writing, at no charge, the name of the individual who participated in the decision to uphold the denial. The initial adverse benefit determination, as well as an adverse benefit determination following a Stage 1 or Stage 2 Medical Necessity Appeal, shall be culturally and linguistically appropriate. It shall include information sufficient to identify the claim involved, including date of service, health care Provider, claim amount (if applicable) and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and treatment code and its corresponding meaning. Any such request for such diagnosis and treatment information following an initial adverse benefit determination shall be responded to as soon as practicable, and the request itself shall not be considered a request for a Stage 1, Stage 2 or External Review. Standard Internal Administrative Appeals Level 1 Standard Administrative Appeal The Appeal must be filed within one hundred-eighty (180) days of receipt of the initial adverse benefit determination. Pre-service Appeal. An Appeal for benefits that, under the terms of this plan, must be precertified or Preapproved (either in whole or in part) before medical care is obtained in order for coverage to be available. A Level 1 Pre-service Appeal is completed and a decision letter providing written notice of the decision with an explanation of the Appeal rights is sent within fifteen (15) days of receipt of Appeal request.
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Post-service Appeal. An Appeal for benefits that is not pre-service in nature. (Post-service Appeals concerning claims for services that the Member has already obtained do not qualify for review as Urgent/Expedited Appeals.) A Level 1 Post-service Appeal is completed and a decision letter providing written notice of the decision with an explanation of the Appeal rights is sent within thirty (30) days of receipt of Appeal request. Level 2 Standard Administrative Appeal If not satisfied with the decision from the Level 1 Appeal, a Member may file a Level 2 Appeal within sixty (60) calendar days of receipt of the Level 1 Appeal decision from the HMO for pre- and post-service. To file a Level 2 Appeal, call, write or fax the AmeriHealth NJ Appeals Unit Department at the address and numbers listed above. A Member has the right to present their Appeal before the panel. The Appeal can also be presented by the Member’s Provider or authorized representative. (See Authorizing Someone to Represent You above for information about authorizations.) The Level 2 Appeal Panel is composed of Plan management staff who have had no previous involvement with the case and who are not subordinate to the original reviewer. The Level 2 Appeal Panel will review and render a decision on the Appeal within fifteen (15) calendar days from receipt of a Pre- or Post-service Appeal. The Level 2 Appeal Panel meetings are a forum through which Members each have the opportunity to present their issues in an informal setting that is not open to the public. Members of the press may only attend in their personal capacity as a Member's authorized representative or to provide general, personal assistance. The committee proceedings may not be electronically recorded. A Member will be sent the decision of the Level 2 Appeal Panel in writing within the timeframes noted above. The Level 2 decision is final. External Review is not available for administrative issues. Standard Internal Medical Necessity Appeals Stage 1 Standard Medical Necessity Appeal The Appeal must be filed within one hundred-eighty (180) days of receipt of the initial utilization management determination. Pre-service Appeal. An Appeal for benefits that, under the terms of this Plan, must be precertified or Preapproved (either in whole or in part) before medical care is obtained in order for coverage to be available. A Stage 1 Pre-service Appeal is completed and a decision letter providing written notice of the decision with an explanation of the Appeal rights is sent within five (5) days of receipt of Appeal request. Post-service Appeal. An Appeal for benefits that is not pre-service in nature. (Post-service Appeals concerning claims for services that the member has already obtained do not qualify for review as Urgent/Expedited Appeals.) A Stage 1 Post-service Appeal is completed and a decision letter providing written notice of the decision with an explanation of the Appeal rights is sent within five (5) business days of receipt of Appeal request.
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Stage 2 Standard Medical Necessity Appeal If not satisfied with the decision from the Stage 1 Appeal, a Member may file a Stage 2 Appeal within 180 calendar days of receipt of the Stage 1 Appeal decision from the HMO for pre- and post-service. To file a Stage 2 Appeal, call, write or fax the AmeriHealth NJ Appeals Unit Department at the address and numbers listed above. The HMO will send a written acknowledgement of receipt of the Stage 2 Appeal to the Member, Member’s Provider or authorized representative filing the Appeal within 10 business days. A Member has the right to present their Appeal before the panel. The Appeal can also be presented by the Member’s Provider or authorized representative. (See Authorizing Someone to Represent You above for information about authorizations.) The Stage 2 Appeal Panel is composed of persons who have had no previous involvement with the case and who are not subordinate to the original reviewer. For Medical Necessity issues, at least one of these Panel members is a medical director employed by the HMO. This Physician holds an active, unrestricted license to practice medicine. The Stage 2 Appeal Panel will review and render a decision on the Appeal within fifteen (15) calendar days from receipt of a Pre- or Post-service Appeal. The Stage 2 Appeal Panel meetings are a forum through which Members each have the opportunity to present their issues in an informal setting that is not open to the public. Members of the press may only attend in their personal capacity as a Member's authorized representative or to provide general, personal assistance. Members may not audiotape or videotape the committee proceedings. A Member will be sent the decision of the Stage 2 Appeal Panel in writing within the timeframes noted above. The decision is final unless the Member chooses to file an External Review for medical judgment and for issues involving rescissions of coverage (except for non-payment of premiums). The External Review process is noted below. Please note that an External Review is not available for administrative issues. Internal Urgent/ Expedited Appeals The Internal Urgent/Expedited Appeals process mirrors the Standard Internal Appeal process with the exception of timeframes. An Appeal concerning an Urgent/Expedited Care claim may be submitted orally or in writing. The expedited review is completed promptly based on the member’s health condition, but no later than seventy two (72) hours after receipt of the Urgent/Expedited Appeal request by the HMO with twenty-four (24) hours allotted for Stage 1 and forty-eight (48) hours for Stage 2 Urgent/Expedited Appeals. The HMO notifies the Member or authorized representative by telephone of the determination. The determination is sent in writing within twenty-four (24) hours after the Member or authorized representative has received the verbal notification. If not satisfied with the Standard Internal or Urgent/Expedited Appeal decision from the HMO, the Member or authorized representative has the right to initiate an External Review as described below.
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External Review. Available for any adverse determination that involves medical judgment as determined by the external reviewer and for rescissions of coverage (except for non-payment of premiums). If not satisfied with the outcome of the Stage 2 Appeal, the Member or authorized representative may initiate an External Review. For most health plans, External Review is conducted by an Independent Utilization Review Organization (IURO) consistent with processes mandated by New Jersey state laws. For plans subject to New Jersey state-mandated requirements, the Member or authorized representative may initiate the External Review within four (4) months of receipt of the Stage 2 determination to an IURO. If the IURO accepts the External Review, it will issue a decision within forty-five (45) days of receiving all necessary documentation to complete the review. A decision reached by an IURO is binding. A Member or authorized representative may Appeal directly to the IURO if the HMO waives its right to an Internal Appeal or fails to meet the timeframes for completing Stage 1 or Stage 2 of the Internal Appeals process. To request an External Review, follow the instructions in the decision letter for the HMO’s Stage 2 Internal Appeal.
*** Also, please note that the Appeal procedures stated above may change due to changes in the applicable state and federal laws and regulations, to satisfy standards of certain recognized accrediting organizations or to otherwise improve the Member Appeals process. For additional information, contact Customer Service at the telephone number listed on the back of the Member’s Identification Card. If your health Plan is subject to the requirements of the Employee Retirement Income Security Act (ERISA), following an Appeal a Member may have the right to bring civil action under Section 502(a) of the Act. For questions about Member rights, this notice, or for assistance, contact the Employee Benefits Security Administration at 1-866-444-EBSA (TTY: 711). Additionally, a consumer assistance program may be able to assist at:
New Jersey Department of Banking and Insurance 20 West State Street, PO Box 329 Trenton, NJ 08625 1-800-446-7467 (TTY: 711) 1-888-393-1062 (appeals) (TTY: 711) http://www.state.nj.us/dobi/consumer.htm
If the HMO fails to “strictly adhere” to the Internal Appeals process, a Member may initiate an External Review or file appropriate legal action under state law or ERISA unless:
Violation was de minimis (minimal).
Did not cause (or likely to cause) prejudice or harm to the claimant.
Was for good cause or due to matters beyond the control of the insurer/plan.
In the context of a good faith exchange of information with the claimant.
Not part of a pattern or practice of violations.
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Upon request of the consumer, the Ombudsman may conduct a review of any disputed insurance claim settlement where there is reasonable cause to believe that an insurer has failed or refused to settle a claim in accordance with the provisions of the Contract or has engaged in any practice that may constitute a violation of state laws. All Complaints should be sent to:
The Office of Insurance Claims Ombudsman 20 West State Street P.O. Box 472 Trenton, NJ 08625-0472 Telephone: (800) 446-7467 Telefax: (609) 292-2431 [email protected]
CONTINUATION OF CARE We shall provide written notice to each Member at least 30 business days prior to the termination or withdrawal from Our Provider Network of a Member’s PCP and any other Provider from which the Member is currently receiving a course of treatment, as reported to Us. The 30-day prior notice may be waived in cases of immediate termination of a health care professional based on a breach of contract by the health care professional, a determination of fraud, or where Our medical director is of the opinion that the health care professional is an imminent danger to the patient or the public health, safety or welfare. We shall assure continued coverage of covered services at the contract rate by a terminated health care professional for up to four months in cases where it is Medically Necessary and Appropriate for the Member to continue treatment with the terminated health care professional. In case of pregnancy of a Member, coverage of services for the terminated health care professional shall continue to the postpartum evaluation of the Member, up to six weeks after the delivery. With respect to pregnancy, Medical Necessity and Appropriateness shall be deemed to have been demonstrated. For a Member who is receiving post-operative follow-up care, We shall continue to cover the services rendered by the health care professional for the duration of the treatment or for up to six months, whichever occurs first. For a Member who is receiving oncological treatment or psychiatric treatment, We shall continue to cover services rendered by the health care professional for the duration of the treatment or for up to 12 months, whichever occurs first. For a Member receiving the above services in an acute care Facility, We will continue to provide coverage for services rendered by the health care professional regardless of whether the acute care Facility is under contract or agreement with Us. Services shall be provided to the same extent as provided while the health care professional was employed by or under contact with Us. Reimbursement for services shall be pursuant to the same schedule used to reimburse the health care professional while the health care professional was employed by or under contract with Us.
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If a Member is admitted to a health care Facility on the date the Contract is terminated, We shall continue to provide benefits for the Member until the date the Member is discharged from the Facility or exhaustion of the Member’s benefits under the Contract, whichever occurs first. We shall not continue services in those instance in which the health care professional has been terminated based upon the opinion of Our medical director that the health care professional is an imminent danger to a patient or to the public health, safety and welfare, a determination of fraud or a breach of contract by a health care professional. The Determination of the Medical Necessity and Appropriateness of a Member’s continued treatment with a health care professional shall be subject to the appeal procedures set forth in the Contract. We shall not be liable for any inappropriate treatment provided to a Member by a health care professional who is no longer employed by or under contract with Us. If We refer a Member to a Non-Network provider, the service or supply shall be covered as a Network service or supply. We are fully responsible for payment to the health care professional and the Member’s liability shall be limited to any applicable Network Copayment, or Coinsurance for the service or supply.
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COVERED SERVICES & SUPPLIES Members are entitled to receive the benefits in the following sections when Medically Necessary and Appropriate, subject to the payment by Members of applicable copayments or Coinsurance as stated in the applicable Schedule of Services and Supplies and subject to the terms, conditions and limitations of the Contract. Read the entire Contract to determine what treatment, services and supplies are limited or excluded. (a) OUTPATIENT SERVICES. The following services are covered only at the Primary Care
Physician’s office selected by a Member, or elsewhere upon prior written Referral by a Member's Primary Care Physician: 1. Office visits during office hours, and during non-office hours when Medically
Necessary and Appropriate. 2. Home visits by a Member's Primary Care Physician. 3. Periodic health examinations to include: a. Well child care from birth including immunizations; b. Routine physical examinations, including eye examinations; c. Routine gynecologic exams and related services; d. Routine ear and hearing examination; and
e. Routine allergy injections and immunizations (but not if solely for the purpose of travel or as a requirement of a Member's employment).
4. Diagnostic Services. 5. Casts and dressings. 6. Ambulance service when certified in writing as Medically Necessary and
Appropriate by a Member's Primary Care Physician and Pre-Approved by Us. 7. Procedures and Prescription Drugs to enhance fertility, except where specifically
excluded in the Contract. Subject to Pre-Approval We cover charges for: artificial insemination; and standard dosages, lengths of treatment and cycles of therapy of Prescription Drugs used to stimulate ovulation for artificial insemination or for unassisted conception. The Prescription Drugs noted in this section are subject to the terms and conditions of the Prescription Drugs section of the Contract.
8. Orthotic or Prosthetic Appliances We cover Orthotic Appliances or Prosthetic Appliances if the Member’s Practitioner determines the appliance is medically necessary. The deductible, coinsurance or copayment as applicable to a non-specialist physician visit for treatment of an Illness or Injury will apply to the Orthotic Appliance or Prosthetic Appliance.
The Orthotic Appliance or Prosthetic Appliance may be obtained from any licensed orthotist or prosthetist or any certified pedorthist in Our Network. Benefits for the appliances will be provided to the same extent as other Covered Services and Supplies under the Contract.
9. Durable Medical Equipment when ordered by a Member's Primary Care Physician
and arranged through Us. Items such as walkers, wheelchairs and hearing aids are examples of durable medical equipment that are also habilitative devices.
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10. Nutritional Counseling for the management of disease entities which have a specific diagnostic criteria that can be verified. The nutritional counseling must be prescribed by a Member’s Primary Care Physician and Pre-Approved by Us.
11. Dental x-rays when related to Covered Services. 12. Oral surgery in connection with bone fractures, removal of tumors and
orthodontogenic cysts, and other surgical procedures, as We approve. 13. Food and Food Products for Inherited Metabolic Diseases: We cover
charges incurred for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods (enteral formula) and low protein modified food products as determined to be medically necessary by a Member’s Practitioner.
For the purpose of this benefit: “inherited metabolic disease” means a disease caused by an inherited abnormality of body chemistry for which testing is mandated by law; “low protein modified food product” means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a Practitioner for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and “medical food” means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under the direction of a Practitioner.
14. Specialized non-standard infant formulas are covered to the same extent and subject to the same terms and conditions as coverage is provided under this Contract for Prescription Drugs. We cover specialized non-standard infant formulas provided: a) The Child’s Practitioner has diagnosed the Child as having multiple food
protein intolerance and has determined the formula to be medically necessary; and
b) The Child has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk.
We may review continued Medical Necessity and Appropriateness of the specialized infant formula.
15. Unless otherwise provided in the Charges for the Treatment of Hemophilia section below, Blood, blood products, blood transfusions and the cost of testing and processing blood. But We do not cover blood which has been donated or replaced on behalf of the Member.
16. Charges for the Treatment of Hemophilia. The Providers in Our Network providing Medically Necessary and Appropriate home treatment services for bleeding episodes associated with hemophilia shall comply with standards adopted by the Department of Health and Senior Services in consultation with the Hemophilia Association of New Jersey.
We will cover the services of a clinical laboratory at a Hospital with a state-designated outpatient regional care center regardless of whether the Hospital’s clinical laboratory is a Network Provider if the Member’s Practitioner determines that the Hospital’s clinical laboratory is necessary because: a) the results of laboratory tests are medically necessary immediately or sooner than the normal return time for Our network clinical laboratory; or b) accurate test results need to be determined by closely supervised procedures in venipuncture and laboratory techniques in controlled environments that cannot be achieved by Our Network clinical laboratory.
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We will pay the Hospital’s clinical laboratory for the laboratory services at the same rate We would pay a Network clinical laboratory for comparable services. 17. Colorectal Cancer Screening We provide coverage for colorectal cancer
screening provided to a Member age 50 or over and to younger Members who are considered to be high risk for colorectal cancer. Coverage will be provided, subject to all the terms of this Contract, and the following limitations:
Subject to the American Cancer Society guidelines, and medical necessity as determined by the Member’s Practitioner in consultation with the Member regarding methods to use, We will cover:
a) Annual gFOBT (guaiac-based fecal occult blood test) with high test sensitivity for cancer;
b) Annual FIT (immunochemical-based fecal occult blood test) with high test sensitivity for cancer;
c) Stool DNA (sDNA) test with high sensitivity for cancer d) flexible sigmoidoscopy, e) colonoscopy; f) contrast barium enema; g) Computed Tomography (CT) Colonography h) any combination of the services listed in items a – g above; or i) any updated colorectal screening examinations and laboratory tests
recommended in the American Cancer Society guidelines.
We will provide coverage for the above methods at the frequency recommended by the most recent published guidelines of the American Cancer Society and as determined to be medically necessary by the Member’s practitioner in consultation with the Member.
High risk for colorectal cancer means a Member has: a) A family history of: familial adenomatous polyposis, heriditary non-polyposis
colon cancer; or breast, ovarian, endometrial or colon cancer or polyps; b) Chronic inflammatory bowel disease; or c) A background, ethnicity or lifestyle that the practitioner believes puts the person
at elevated risk for colorectal cancer. 18) Newborn Hearing Screening We provide coverage up to a maximum of 28
days following the date of birth for screening for newborn hearing loss by appropriate electrophysiologic screening measures. In addition, We provide coverage between age 29 days and 36 months for the periodic monitoring of infants for delayed onset hearing loss.
19) Hearing Aids We provide coverage for medically necessary services incurred in the purchase of a hearing aid for a Member age 15 or younger. Coverage includes the purchase of one hearing aid for each hearing-impaired ear every 24 months. Coverage for all other medically necessary services incurred in the purchase of a hearing aid is unlimited. Such medically necessary services include fittings, examinations, hearing tests, dispensing fees, modifications and repairs, ear molds and headbands for bone-anchored hearing implants. The hearing aid must be recommended or prescribed by a licensed physician or audiologist.
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The deductible, coinsurance or copayment applicable to Durable Medical Equipment will apply to the purchase of hearing aid. The deductible, coinsurance or copayment as applicable to a non-specialist physician visit for treatment of an Illness or Injury will apply to medically necessary services incurred in the purchase of a hearing aid. Hearing aids are habilitative devices.
20). Orally Administered Anti-Cancer Prescription Drugs As used in this
provision, orally administered anti-cancer prescription drugs means Prescription Drugs that are used to slow or kill the growth of cancerous cells and are administered orally. Such anti-cancer Prescription Drugs does not include those that are prescribed to maintain red or white cell counts, those that treat nausea or those that are prescribed to support the anti-cancer prescription drugs. Any such Prescription Drugs are covered under the Prescription Drugs provision of the Contract.
We cover orally administered anti-cancer prescription drugs that are Medically Necessary and Appropriate as Network Services and Supplies if the Member is receiving care and treatment from a Network Practitioner who writes the prescription for such Prescription Drugs.
Anti-cancer prescription drugs are covered subject to the terms of the Prescription Drugs provision of the Policy as stated above. The Member must pay the deductible and/or coinsurance required for Prescription Drugs. Using the receipt from the pharmacy, the Member may then submit a claim for the anti-cancer prescription drug under this Orally Administered Anti-Cancer Prescription Drugs provision of the Contract. Upon receipt of such a claim We will compare the coverage for the orally-administered anti-cancer prescription drugs as covered under the Prescription Drugs provision to the coverage the Contract would have provided if the Member had received intravenously administered or injected anti-cancer medications from the Network to determine which is more favorable to the Member in terms of copayment, deductible and/or coinsurance. If the Contract provides different copayment, deductible or coinsurance for different places of service, the comparison shall be to the location for which the copayment deductible and coinsurance is more favorable to the Member. If a Member paid a deductible and/or coinsurance under the Prescription Drug provision that exceeds the copayment, deductible and/or coinsurance that would have applied for intravenously administered or injected anti-cancer medications the Member will be reimbursed for the difference.
21) Vision Benefit Subject to the applicable Deductible, Coinsurance or
Copayments shown on the Schedule of Services and Supplies, We cover the vision benefits described in this provision for Members through end of the month in which the Member turns age 19. We cover one comprehensive eye examination by a Network ophthalmologist or optometrist in a 12 month period. We cover one pair of lenses, for glasses or contact lenses, in a 12 month period. We cover one pair of frames in a 12 month period. Standard frames refers to frames that are not designer frames such as Coach, Burberry, Prada and other designers.
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We cover charges for a one comprehensive low vision evaluation every 5 years. We cover low vision aids such as high-power spectacles, magnifiers and telescopes and medically-necessary follow-up care. As used in this provision, low vision means a significant loss of vision, but not total blindness.
22) Mammogram Coverage
We cover mammograms provided to a female Member according to the schedule given below. Coverage is provided, subject to all the terms of the Contract, and the following limitations:
We will cover: a) one baseline mammogram for a female Member– who is 40 years of age b) one mammogram, every year, for a female Member age 40 and older; and c) a mammogram at the ages and intervals the female Member’s Practitioner
deems to be Medically Necessary and Appropriate with respect to a female Member who is less than 40 years of age and has a family history of breast cancer or other breast risk factors.
In addition, if the conditions listed below are satisfied after a baseline mammogram We will cover: a) an ultrasound evaluation; b) a magnetic resonance imaging scan; c) a three-dimensional mammography; and d) other additional testing of the breasts.
The above additional services will be covered if one of following conditions are satisfied. a) The mammogram demonstrates extremely dense breast tissue; b) The mammogram is abnormal within any degree of breast density including
not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue; or
c) If the female Member has additional risk factors of breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or other indications as determined by the female Member’s Practitioner.
Please note that mammograms and the additional testing described above when warranted as described above, are included under the Preventive Care provision. (b) SPECIALIST DOCTOR BENEFITS. Services are covered when rendered by a
Network specialist doctor at the doctor's office or any other Network Facility or a Network Hospital outpatient department during office or business hours upon prior written Referral by a Member's Primary Care Physician.
(c) INPATIENT HOSPICE, HOSPITAL, REHABILITATION CENTER & SKILLED
NURSING CENTER BENEFITS. The following services are covered when hospitalized by a Network Provider upon prior written referral from a Member's Primary Care Physician, only at Network Hospitals and Network Providers (or at Non-Network facilities
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subject to Our Pre-Approval); however, Network Skilled Nursing Facility services and supplies are limited to those which constitute Skilled Nursing Care and Hospice services are subject to Our Pre-Approval: 1. Semi-private room and board accommodations
Except as stated below, We provide coverage for Inpatient care for: a) a minimum of 72 hours following a modified radical mastectomy; and b) a minimum of 48 hours following a simple mastectomy. Exception: The minimum 72 or 48 hours, as appropriate, of Inpatient care will not be covered if the Member, in consultation with the Network Provider, determine that a shorter length of stay is Medically Necessary and Appropriate.
As an exception to the Medically Necessary and Appropriate requirement of the Contract, We also provide coverage for the mother and newly born child for: a) up to 48 hours of inpatient care in a Network Hospital following a vaginal
delivery; and b) a minimum of 96 hours of Inpatient care in a Network Hospital following a
cesarean section. We provide childbirth and newborn coverage subject to the following: a) the attending Practitioner must determine that Inpatient care is medically
necessary; or b) the mother must request the Inpatient care. As an alternative to the minimum level of Inpatient care described above, the mother may elect to participate in a home care program provided by Us.
2. Private accommodations will be provided only when Pre-Approved by Us. If a Member occupies a private room without such certification, the Member shall be directly liable to the Hospice, Hospital, Rehabilitation Center or Skilled Nursing Facility for the difference between payment by Us to the Hospice, Hospital, Rehabilitation Center or Skilled Nursing Facility of the per diem or other agreed upon rate for semi-private accommodation established between Us and the Network Hospice, Network Hospital, Network Rehabilitation Center or Network Skilled Nursing Facility and the private room rate.
3. General nursing care 4. Use of intensive or special care facilities 5. X-ray examinations including CAT scans but not dental x-rays 6. Use of operating room and related facilities 7. Magnetic resonance imaging "MRI" 8. Drugs, medications, biologicals 9. Cardiography/Encephalography 10. Laboratory testing and services 11. Pre- and post-operative care 12. Special tests 13. Nuclear medicine 14. Therapy Services 15. Oxygen and oxygen therapy 16. Anesthesia and anesthesia services 17. Blood, blood products and blood processing 18. Intravenous injections and solutions 19. Surgical, medical and obstetrical services.
We also cover reconstructive breast Surgery, Surgery to restore and achieve symmetry between the two breasts and the cost of prostheses following a mastectomy on one breast or both breasts. We also cover treatment of the physical
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complications of mastectomy, including lymphedemas.
We also cover surgical treatment of morbid obesity for one surgical procedure within a two-year period, measured from the date of the first surgical procedure to treat morbid obesity, unless a multi-stage procedure is planned and We authorize coverage for such multi-stage procedure. In addition, We will cover surgery required as a result of complications that may arise from surgical treatment of morbid obesity.
For the purpose of this coverage, morbid obesity means a body mass index that is greater than 40 kilograms per meter squared; or equal to or greater than 35 kilograms per meter squared with a high risk comorbid condition. Body mass index is calculated by dividing the weight in kilograms by the height in meters squared.
20. The following transplants: Cornea, Kidney, Lung, Liver, Heart, Pancreas and Intestines.
21. Allogeneic bone marrow transplants. 22. Autologous Bone Marrow Transplant and Associated Dose-Intensive
Chemotherapy, but only if performed by institutions approved by the National Cancer Institute, or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists;
23. Peripheral Blood Stem Cell Transplants, but only if performed by institutions approved by the National Cancer Institute, or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists.
24. Donor’s costs associated with transplants if the donor does not have health coverage that would cover the medical costs associated with his or her role as a donor. We do not cover costs for travel, accommodations or comfort items.
(d) BENEFITS FOR MENTAL ILLNESS OR SUBSTANCE ABUSE. We cover treatment of
Mental Illness or Substance Abuse the same way We would for any other illness, if such treatment is prescribed by a Network Provider upon prior written by a Member's Primary Care Physician. We do not pay for Custodial care, education or training.
Inpatient or day treatment may be furnished by any Network Provider that is licensed, certified or State approved facility, including but not limited to: a) a Hospital b) a detoxification Facility licensed under New Jersey P.L. 1975, Chapter 305; c) a licensed, certified or state approved residential treatment Facility under a program
which meets the minimum standards of care of the Joint Commission; d) a Mental Health Center; or e) a Substance Abuse Center.
(e) EMERGENCY CARE BENEFITS - WITHIN AND OUTSIDE OUR SERVICE AREA. The
following services are covered without prior written Referral by a Member's Primary Care Physician in the event of an Emergency as Determined by Us.
1. A Member's Primary Care Physician is required to provide or arrange for on-call
coverage twenty-four (24) hours a day, seven (7) days a week. Unless a delay would be detrimental to a Member's health, Member shall call a Member's Primary Care Physician or Us prior to seeking Emergency treatment.
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2. We will cover the cost of Emergency medical and hospital services performed within or outside our service area without a prior written Referral only if: a. Our review Determines that a Member's symptoms were severe and
delay of treatment would have been detrimental to a Member's health, the symptoms occurred suddenly, and Member sought immediate medical attention.
b. The service rendered is provided as a Covered Service or Supply under the Contract and is not a service or supply which is normally treated on a non-Emergency basis; and
c. We and the Member's Primary Care Physician are notified within 48 hours of the Emergency service and/or admission and We are furnished with written proof of the occurrence, nature and extent of the Emergency services within 30 days. A Member shall be responsible for payment for services received unless We Determine that a Member's failure to do so was reasonable under the circumstances. In no event shall reimbursement be made until We receive proper written proof.
3. In the event a Member is Hospitalized in a Non-Network Facility, coverage will only be provided until the Member is medically able to travel or to be transported to a Network Facility. If the Member elects to continue treatment with Non-Network Providers, We shall have no responsibility for payment beyond the date the Member is Determined to be medically able to be transported. In the event that transportation is Medically Necessary and Appropriate, We will cover the amount We Determine to be the Reasonable and Customary cost. Reimbursement may be subject to payment by Members of all Copayments which would have been required had similar benefits been provided upon prior written Referral to a Network Provider.
4. Coverage for Emergency services includes only such treatment necessary to treat the Emergency. Any elective procedures performed after a Member has been admitted to a Facility as the result of an Emergency shall require prior written or the Member shall be responsible for payment. The Copayment for an emergency room visit will be credited toward the Hospital Inpatient Copayment if a Member is admitted as an Inpatient to the Hospital as a result of the Emergency.
5. Coverage for Emergency and Urgent Care include coverage of trauma services at any designated level I or II trauma center as Medically Necessary and Appropriate, which shall be continued at least until, in the judgment of the attending physician, the Member is medically stable, no longer requires critical care, and can be safely transferred to another Facility. We also provides coverage for a medical screening examination provided upon a Member’s arrival in a Hospital, as required to be performed by the Hospital in accordance with Federal law, but only as necessary to determine whether an Emergency medical condition exists. . Please note that the “911” Emergency response system may be used whenever a Covered person has a potentially life-threatening condition. Information on the use of the “911” system is included on the identification card.
(f) THERAPY SERVICES. The following Services are covered when rendered by a
Network Provider upon prior written Referral by a Member's Primary Care Physician. Subject to the stated limits, We cover the Therapy Services listed below. We cover other types of Therapy Services provided they are performed by a licensed Provider, are Medically Necessary and Appropriate and are not Experimental or Investigational.
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a. Chelation Therapy - means the administration of drugs or chemicals to remove toxic concentrations of metals from the body.
b. Chemotherapy - the treatment of malignant disease by chemical or biological antineoplastic agents.
c. Dialysis Treatment - the treatment of an acute renal failure or a chronic irreversible renal insufficiency by removing waste products from the body. This includes hemodialysis and peritoneal dialysis.
d. Radiation Therapy - the treatment of disease by x-ray, radium, cobalt, or high energy particle sources. Radiation therapy includes rental or cost of radioactive materials. Diagnostic Services requiring the use of radioactive materials are not radiation therapy.
e. Respiration Therapy - the introduction of dry or moist gases into the lungs. f. Cognitive Rehabilitation Therapy - the retraining of the brain to perform
intellectual skills which it was able to perform prior to disease, trauma, Surgery, or previous therapeutic process; or the training of the brain to perform intellectual skills it should have been able to perform if there were not a congenital anomaly.
g. Speech Therapy -except as stated below, treatment for the correction of a speech impairment resulting from Illness, Surgery, Injury, congenital anomaly, or previous therapeutic processes. Exception: For a Member who has been diagnosed with a biologically-based mental illness, speech therapy means treatment of a speech impairment.
Coverage for Cognitive Rehabilitation Therapy and Speech Therapy, combined, is limited to 30 visits per Calendar Year. h. Occupational Therapy - except as stated below, treatment to restore a physically
disabled person's ability to perform the ordinary tasks of daily living. Exception: For a Member who has been diagnosed with a biologically-based mental illness, occupational therapy means treatment to develop a Member’s ability to perform the ordinary tasks of daily living.
i. Physical Therapy - except as stated below, the treatment by physical means to relieve pain, restore maximum function, and prevent disability following disease, Injury or loss of limb. Exception: For a Member who has been diagnosed with a biologically-based mental illness, physical therapy means treatment to develop a Member’s physical function.
Coverage for Occupational Therapy and Physical Therapy, combined, is limited to 30 visits per Calendar Year. j. Infusion Therapy - the administration of antibiotic, nutrients, or other therapeutic
agents by direct infusion. Note: The limitations on Therapy Services contained in this Therapy Services provision do not apply to any Therapy Services that are received under the Home Health Care provision or to therapy services received under the Diagnosis and Treatment of Autism or Other Developmental Disabilities provision.
(g) DIAGNOSIS AND TREATMENT OF AUTISM AND OTHER DEVELOPMENTAL
DISABILITIES We provide coverage for charges for the screening and diagnosis of autism and other developmental disabilities. If a Member’s primary diagnosis is autism or another developmental disability We provide coverage for the following medically necessary therapies as prescribed through a treatment plan. These are habilitative services in that they are provided to develop
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rather than restore a function. The therapy services are subject to the benefit limits set forth below: a) occupational therapy where occupational therapy refers to treatment to develop a
Member’s ability to perform the ordinary tasks of daily living; b) physical therapy where physical therapy refers to treatment to develop a Member’s
physical function; and c) speech therapy where speech therapy refers to treatment of a Member’s speech
impairment.
Coverage for occupational therapy and physical therapy combined is limited to 30 visits per Calendar Year for the treatment of conditions other than autism. Coverage for speech therapy is limited to 30 visits per Calendar Year for the treatment of conditions other than autism. These therapy services are covered whether or not the therapies are restorative. The therapy services covered under this provision do not reduce the available therapy visits available under the Therapy Services provision. .
If a Member’s primary diagnosis is autism, in addition to coverage for the therapy services as described above, We also cover medically necessary behavioral interventions based on the principles of applied behavior analysis and related structured behavioral programs as prescribed through a treatment plan.
The treatment plan(s) referred to above must be in writing, signed by the treating physician, and must include: a diagnosis, proposed treatment by type, frequency and duration; the anticipated outcomes stated as goals; and the frequency by which the treatment plan will be updated. We may request additional information if necessary to determine the coverage under the Contract. We may require the submission of an updated treatment plan once every six months unless We and the treating physician agree to more frequent updates. Member Person: a) is eligible for early intervention services through the New Jersey Early
Intervention System; and b) has been diagnosed with autism or other developmental disability; and c) receives physical therapy, occupational therapy, speech therapy, applied
behavior analysis or related structured behavior services the portion of the family cost share attributable to such services is a Covered Service under this Contract. The deductible, coinsurance or copayment as applicable to a non-specialist physician visit for treatment of an Illness or Injury will apply to the family cost share.
The therapy services a Member receives through New Jersey Early Intervention do not reduce the therapy services otherwise available under this Diagnosis and Treatment of Autism and Other Disabilities provision.
(h) HOME HEALTH CARE. The following Services are covered upon prior written referral
from a Member's Primary Care Physician. When home health care can take the place of Inpatient care, We cover such care furnished to a Member under a written home health care plan. We cover all Medically Necessary and Appropriate services or supplies, such as: a) Routine Nursing Care furnished by or under the supervision of a registered
Nurse;
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b) physical therapy; c) occupational therapy; d) medical social work; e) nutrition services; f) speech therapy; g) home health aide services; h) medical appliances and equipment, drugs and medications, laboratory services
and special meals to the extent such items and services would have been covered under this Contract if the Member had been in a Hospital; and
i) any Diagnostic or therapeutic service, including surgical services performed in a Hospital Outpatient department, a Practitioner's office or any other licensed health care Facility, provided such service would have been covered under the Contract if performed as Inpatient Hospital services.
Payment is subject to all of the terms of this Contract and to the following conditions:
a. The Member’s Practitioner must certify that home health care is needed in place
of Inpatient care in a recognized Facility. Home health care is covered only in situations where continuing hospitalization or confinement in a Skilled Nursing Facility or Rehabilitation Center would otherwise have been required if home health care were not provided.
b. The services and supplies must be: 1. ordered by the Member’s Practitioner; 2. included in the home health care plan: and 3. furnished by, or coordinated by, a Home Health Agency according to the
written home health care plan. The services and supplies must be furnished by recognized health care professionals on a part-time or intermittent basis, except when full-time or 24 hour service is needed on a short-term (no more than three-day) basis. c. The home health care plan must be set up in writing by the Member’s Practitioner
within 14 days after home health care starts. And it must be reviewed by the Member’s Practitioner at least once every 60 days.
d. We do not pay for: 1. services furnished to family members, other than the patient; or 2. services and supplies not included in the home health care plan.
Any visit by a member of a home health care team on any day shall be considered as one home health care visit. Benefits for Home Health Care are provided for no more than 60 visits per Calendar Year.
(i) Hospice Care if Members are terminally Ill or terminally Injured with life expectancy of
six months or less, as certified by the Member's Primary Care Physician. Services may include home and Hospital visits by nurses and social workers; pain management and symptom control; instruction and supervision of family members, inpatient care; counseling and emotional support; and other home health care benefits listed above.
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(j) DENTAL CARE AND TREATMENT. Dental benefits available to all Members The following services are covered for all Members when rendered by a Network Practitioner upon prior Referral by a Member's Primary Care Physician. We cover: 1) the diagnosis and treatment of oral tumors and cysts; and 2) the surgical removal of bony impacted teeth.
We also cover treatment of an Injury to natural teeth or the jaw, but only if: 1) the Injury was not caused, directly or indirectly by biting or chewing; and 2) all treatment is finished within 6 months of the date of the Injury. Treatment includes replacing natural teeth lost due to such Injury. But in no event do We cover orthodontic treatment.
Additional benefits for a Child under age 6 For a Member who is severely disabled or who is a Child under age 6, We cover: a) general anesthesia and Hospitalization for dental services; and b) dental services rendered by a dentist regardless of where the dental services are
provided for a medical condition covered by the Contract which requires Hospitalization or general anesthesia.
(k) TREATMENT FOR TEMPOROMANDIBULAR JOINT DISORDER (TMJ) The following
services are covered when rendered by a Network Practitioner upon prior Referral by a Member's Primary Care Physician. We cover services and supplies for the Medically Necessary and Appropriate surgical and non-surgical treatment of TMJ in a Member. However, with respect to coverage of TMJ, We do not cover any services or supplies for orthodontia, crowns or bridgework.
(l) THERAPEUTIC MANIPULATION The following services are covered when rendered
by a Network Practitioner upon prior Referral by a Member's Primary Care Physician. We limit what We cover for therapeutic manipulation to 30 visits per Calendar Year. And We cover no more than two modalities per visit. Services and supplies beyond 30 visits are not covered.
(m) CLINICAL TRIAL The coverage described in this provision applies to Members who are
eligible to participate in an approved clinical trial, Phase I, II, III and/or IV according to the trial protocol with respect to the treatment of cancer or another life threatening condition. We provide coverage for the clinical trial if the Member’s practitioner is participating in the clinical trial and has concluded that the Member’s participation would be appropriate; or the Member provides medical and scientific information establishing that his or her participation in the clinical trial would be appropriate. We provide coverage of routine patient costs for items and services furnished in connection with participation in the clinical trial. We will not deny a qualified Member participation in an approved clinical trial with respect to the treatment of cancer or another life threatening disease or condition. We will not deny or limit or impose additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in the clinical trial. We will not discriminate against the Member on the basis of the Member’s participation in the clinical trial.
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NON-COVERED SERVICES AND SUPPLIES THE FOLLOWING ARE NOT COVERED SERVICES UNDER THE CONTRACT. Care or treatment by means of acupuncture except when used as a substitute for other forms of anesthesia. The amount of any charge which is greater than an Allowed Charge. Services for ambulance for transportation from a Hospital or other health care Facility, unless Member is being transferred to another Inpatient health care Facility. Broken Appointments. Blood or blood plasma which is replaced by or for a Member. Care and/or treatment by a Christian Science Practitioner. Completion of claim forms. Services or supplies related to Cosmetic Surgery, except as otherwise stated in the Contract; complications of Cosmetic Surgery; drugs prescribed for cosmetic purposes Services related to Custodial or domiciliary care. Dental care or treatment, including appliances and dental implants, except as otherwise stated in the Contract. Care or treatment by means of dose intensive chemotherapy, except as otherwise stated in the Contract. Services or supplies, the primary purpose of which is educational providing the Member with any of the following: training in the activities of daily living; instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities except as otherwise stated in the Contract. Experimental or Investigational treatments, procedures, hospitalizations, drugs, biological products or medical devices, except as otherwise stated in the Contract. Extraction of teeth, except for bony impacted teeth or as otherwise covered under the Contract. Services or supplies for or in connection with: a) except as otherwise stated in the Contract, exams to determine the need for (or changes of)
eyeglasses or lenses of any type; b) eyeglasses or lenses of any type except initial replacements for loss of the natural lens or as
otherwise covered under the Contract; or
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c) eye surgery such as radial keratotomy or lasik surgery, when the primary purpose is to correct myopia (nearsightedness), hyperopia (farsightedness) or astigmatism (blurring).
Services or supplies provided by one of the following members of the Employee's family: spouse, child, parent, in-law, brother, sister or grandparent. Services or supplies furnished in connection with any procedures to enhance fertility which involve harvesting, storage and / or manipulation of eggs and sperm. This includes, but is not limited to the following: a) procedures: in vitro fertilization; embryo transfer; embryo freezing; and Gamete intra-fallopian Transfer (GIFT) and Zygote Intrafallopian Transfer (ZIFT), donor sperm, surrogate motherhood; and b) Prescription Drugs not eligible under the Prescription Drugs section of the Contract ; and c) ovulation predictor kits. See also the separate Exclusion addressing sterilization reversal. Except as otherwise stated in the Hearing Aids and Newborn Hearing Screening provisions, services or supplies related to hearing aids and hearing examinations to determine the need for hearing aids or the need to adjust them. Services or supplies related to herbal medicine. Services or supplies related to hypnotism. Services or supplies necessary because the Member engaged, or tried to engage, in an illegal occupation or committed or tried to commit an indictable offense in the jurisdiction in which it is committed, or a felony. Exception: As required by 29 CFR 2590.702(b)(2)(iii) this exclusion does not apply to injuries that result from an act of domestic violence or to injuries that result from a medical condition. Except as stated below, Illness or Injury, including a condition which is the result of disease or bodily infirmity, which occurred on the job and which is covered or could have been covered for benefits provided under workers' compensation, employer's liability, occupational disease or similar law; Exception: This exclusion does not apply to the following persons for whom coverage under workers’ compensation is optional unless such persons are actually covered for workers’ compensation: a self-employed person or a partner of a limited liability partnership, members of a limited liability company or partners of a partnership who actively perform services on behalf of the self-employed business, the limited liability partnership, limited liability company or the partnership. Local anesthesia charges billed separately if such charges are included in the fee for the Surgery. Membership costs for health clubs, weight loss clinics and similar programs. Services and supplies related to marriage, career or financial counseling, sex therapy or family therapy, and related services. Any Non-Covered Service or Supply specifically limited or not covered elsewhere in the Contract, or which is not Medically Necessary and Appropriate.
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Non-prescription drugs or supplies, except; a) insulin needles and insulin syringes and glucose test strips and lancets; b) colostomy bags, belts, and irrigators; and c) as stated in the Contract for food and food products for inherited metabolic diseases. Services provided by a pastoral counselor in the course of his or her normal duties as a religious official or practitioner. Personal convenience or comfort items including, but not limited to, such items as TV's, telephones, first aid kits, exercise equipment, air conditioners, humidifiers, saunas, hot tubs. Any service provided without prior written Referral by the Member's Primary Care Physician, except as specified in the Contract. Services related to Private Duty Nursing, except as provided under the Private Duty Nursing section of the Contract. Services or supplies related to rest or convalescent cures. Room and board charges for a Member in any Facility for any period of time during which he or she was not physically present overnight in the Facility. Services or supplies related to Routine Foot Care, except: a) an open cutting operation to treat weak, strained, flat, unstable or unbalanced feet,
metatarsalgia or bunions; b) the removal of nail roots; and c) treatment or removal of corns, calluses or toenails in conjunction with the treatment of
metabolic or peripheral vascular disease. Self-administered services such as: biofeedback, patient-controlled analgesia on an Outpatient basis, related diagnostic testing, self-care and self-help training. Services or supplies: a) eligible for payment under either federal or state programs (except Medicaid and Medicare).
This provision applies whether or not the Member asserts his or her rights to obtain this coverage or payment for these services;
b) for which a charge is not usually made, such as a Practitioner treating a professional or business associate, or services at a public health fair;
c) for which a Member would not have been charged if he or she did not have health care coverage;
d) provided by or in a Government Hospital except as stated below, or unless the services are for treatment:
of a non-service Emergency; or
by a Veterans' Administration Hospital of a non-service related Illness or Injury; Exception: This exclusion does not apply to military retirees, their Dependents and the Dependents of active duty military personnel who are covered under both the Contract and under military health coverage and who receive care in facilities of the Uniformed Services. Sterilization reversal - services and supplies rendered for reversal of sterilization.
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Surgery, sex hormones, and related medical, psychological and psychiatric services to change a Member's sex; services and supplies arising from complications of sex transformation. Telephone consultations. Transplants, except as otherwise listed in the Contract. Transportation; travel. Vision therapy. Vitamins and dietary supplements. Services or supplies received as a result of a war, or an act of war, if the Illness or Injury occurs while the Member is serving in the military, naval or air forces of any country, combination of countries or international organization and Illness or Injury suffered as a result of special hazards incident to such service if the Illness or Injury occurs while the Member is serving in such forces and is outside the home area. Weight reduction or control including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, food or food supplements, appetite suppressants or other medications; exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions, except as otherwise provided in the Surgical Treatment of Morbid Obesity section of this Policy and except as provided in the Nutritional Counseling and Food and Food products for Inherited Metabolic Diseases provisions. Wigs, toupees, hair transplants, hair weaving or any drug if such drug is used in connection with baldness.
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COORDINATION OF BENEFITS AND SERVICES Purpose Of This Provision A Member may be covered for health benefits or services by more than one Plan. For instance, he or she may be covered by this Contract as an Employee and by another plan as a Dependent of his or her spouse. If he or she is covered by more than one Plan, this provision allows Us to coordinate what We pay or provides with what another Plan pays or provides. This provision sets forth the rules for determining which is the Primary Plan and which is the Secondary Plan. Coordination of benefits is intended to avoid duplication of benefits while at the same time preserving certain rights to coverage under all Plans under which the Member is covered.
DEFINITIONS The words shown below have special meanings when used in this provision. Please read these definitions carefully. Throughout this provision, these defined terms appear with their initial letter capitalized. Allowable Expense: The charge for any health care service, supply or other item of expense for which the Member is liable when the health care service, supply or other item of expense is covered at least in part under any of the Plans involved, except where a statute requires another definition, or as otherwise stated below. When this Contract is coordinating benefits with a Plan that provides benefits only for dental care, vision care, prescription drugs or hearing aids, Allowable Expense is limited to like items of expense. AmeriHealth will not consider the difference between the cost of a private hospital room and that of a semi-private hospital room as an Allowable Expense unless the stay in a private room is Medically Necessary and Appropriate. When this Contract is coordinating benefits with a Plan that restricts coordination of benefits to a specific coverage, We will only consider corresponding services, supplies or items of expense to which coordination of benefits applies as an Allowable Expense. Allowed Charge: An amount that is not more than the usual or customary charge for the service or supply as determined by Us, based on a standard which is most often charged for a given service by a Provider within the same geographic area. Claim Determination Period: A Calendar Year, or portion of a Calendar Year, during which a Member is covered by this Contract and at least one other Plan and incurs one or more Allowable Expense(s) under such plans. Plan: Coverage with which coordination of benefits is allowed. Plan includes: a) Group insurance and group subscriber contracts, including insurance continued pursuant to
a Federal or State continuation law;
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b) Self-funded arrangements of group or group-type coverage, including insurance continued pursuant to a Federal or State continuation law;
c) Group or group-type coverage through a health maintenance organization (HMO) or other prepayment, group practice and individual practice plans, including insurance continued pursuant to a Federal or State continuation law;
d) Group hospital indemnity benefit amounts that exceed $150 per day; e) Medicare or other governmental benefits, except when, pursuant to law, the benefits must
be treated as in excess of those of any private insurance plan or non-governmental plan. Plan does not include: a) Individual or family insurance contracts or subscriber contracts; b) Individual or family coverage through a health maintenance organization or under any other
prepayment, group practice and individual practice plans; c) Group or group-type coverage where the cost of coverage is paid solely by the Member
except that coverage being continued pursuant to a Federal or State continuation law shall be considered a Plan;
d) Group hospital indemnity benefit amounts of $150 per day or less; e) School accident –type coverage; f) A State plan under Medicaid. Primary Plan: A Plan whose benefits for a Member’s health care coverage must be determined without taking into consideration the existence of any other Plan. There may be more than one Primary Plan. A Plan will be the Primary Plan if either either “a” or “b” below exist: a) The Plan has no order of benefit determination rules, or it has rules that differ from those
contained in this Coordination of Benefits and Services provision; or b) All Plans which cover the Member use order of benefit determination rules consistent with
those contained in the Coordination of Benefits and Services provision and under those rules, the plan determines its benefits first.
Secondary Plan: A Plan which is not a Primary Plan. If a Member is covered by more than one Secondary Plan, the order of benefit determination rules of this Coordination of Benefits and Services provision shall be used to determine the order in which the benefits payable under the multiple Secondary Plans are paid in relation to each other. The benefits of each Secondary Plan may take into consideration the benefits of the Primary Plan or Plans and the benefits of any other Plan which, under this Coordination of Benefits and Services provision, has its benefits determined before those of that Secondary Plan. PRIMARY AND SECONDARY PLAN We consider each plan separately when coordinating payments. The Primary Plan pays or provides services or supplies first, without taking into consideration the existence of a Secondary Plan. If a Plan has no coordination of benefits provision, or if the order of benefit determination rules differ from those set forth in these provisions, it is the Primary Plan. A Secondary Plan takes into consideration the benefits provided by a Primary Plan when, according to the rules set forth below, the plan is the Secondary Plan. If there is more than one Secondary Plan, the order of benefit determination rules determine the order among the
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Secondary Plans. During each Claim Determination Period, the Secondary Plan(s) will pay up to the remaining unpaid allowable expenses, but no Secondary Plan will pay more than it would have paid if it had been the Primary Plan. The method the Secondary Plan uses to determine the amount to pay is set forth below in the “Procedures to be Followed by the Secondary Plan to Calculate Benefits” section of this provision. The Secondary Plan shall not reduce Allowable Expenses for medically necessary and appropriate services or supplies on the basis that precertification, preapproval, notification or second surgical opinion procedures were not followed. RULES FOR THE ORDER OF BENEFIT DETERMINATION The benefits of the Plan that covers the Member as an employee, member, subscriber or retiree shall be determined before those of the Plan that covers the Member as a Dependent. The coverage as an employee, member, subscriber or retiree is the Primary Plan. The benefits of the Plan that covers the Member as an employee who is neither laid off nor retired, or as a dependent of such person, shall be determined before those for the Plan that covers the Member as a laid off or retired employee, or as such a person’s Dependent. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. The benefits of the Plan that covers the Member as an employee, member, subscriber or retiree, or Dependent of such person, shall be determined before those of the Plan that covers the Member under a right of continuation pursuant to Federal or State law. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. If a child is covered as a Dependent under Plans through both parents, and the parents are neither separated nor divorced, the following rules apply: a) The benefits of the Plan of the parent whose birthday falls earlier in the Calendar Year shall
be determined before those of the parent whose birthday falls later in the Calendar Year. b) If both parents have the same birthday, the benefits of the Plan which covered the parent for
a longer period of time shall be determined before those of plan which covered the other parent for a shorter period of time.
c) Birthday, as used above, refers only to month and day in a calendar year, not the year in which the parent was born.
d) If the other plan contains a provision that determines the order of benefits based on the gender of the parent, the birthday rule in this provision shall be ignored.
If a child is covered as a Dependent under Plans through both parents, and the parents are separated or divorced, the following rules apply: a) The benefits of the Plan of the parent with custody of the child shall be determined first. b) The benefits of the Plan of the spouse of the parent with custody shall be determined
second. c) The benefits of the Plan of the parent without custody shall be determined last.
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d) If the terms of a court decree state that one of the parents is responsible for the health care expenses for the child, and if the entity providing coverage under that Plan has actual knowledge of the terms of the court decree, then the benefits of that plan shall be determined first. The benefits of the plan of the other parent shall be considered as secondary. Until the entity providing coverage under the plan has knowledge of the terms of the court decree regarding health care expenses, this portion of this provision shall be ignored.
If the above order of benefits does not establish which plan is the Primary Plan, the benefits of the Plan that covers the employee, member or subscriber for a longer period of time shall be determined before the benefits of the Plan(s) that covered the person for a shorter period of time.
Procedures to be Followed by the Secondary Plan to Calculate Benefits In order to determine which procedure to follow it is necessary to consider: a) the basis on which the Primary Plan and the Secondary Plan pay benefits; and b) whether the provider who provides or arranges the services and supplies is in the network of
either the Primary Plan or the Secondary Plan. Benefits may be based on the Allowed Charge (AC), or some similar term. This means that the provider bills a charge and the Member may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on an Allowed Charge is called an “AC Plan.” Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule, or some similar term. This means that although a provider, called a network provider, bills a charge, the Member may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan.” Fee Schedule Plans may require that Members use network providers. Examples of such plans are Health Maintenance Organization plans (HMO) and Exclusive Provider organization plans (EPO). If the Member uses the services of a non-network provider, the plan will be treated as an AC Plan even though the plan under which he or she is covered allows for a fee schedule. Examples of such plans are Preferred provider organization plans (PPO) and Point of Service plans (POS). Payment to the provider may be based on a “capitation”. This means that the HMO, EPO or other plans pays the provider a fixed amount per Member. The Member is liable only for the applicable deductible, coinsurance or copayment. If the Member uses the services of a non-network provider, the HMO or other plans will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays providers based upon capitation is called a “Capitation Plan.” In the rules below, “provider” refers to the provider who provides or arranges the services or supplies and “HMO” refers to a health maintenance organization plan and “EPO” refers to Exclusive Provider Organization.
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Primary Plan is an AC Plan and Secondary Plan is an AC Plan The Secondary Plan shall pay the lesser of: a) the difference between the amount of the billed charges and the amount paid by the Primary
Plan; or b) the amount the Secondary Plan would have paid if it had been the Primary Plan. When the benefits of the Secondary Plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in both the Primary Plan and the Secondary Plan, the Allowable Expense shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: a) The amount of any deductible, coinsurance or copayment required by the Primary Plan; or b) the amount the Secondary Plan would have paid if it had been the Primary Plan. The total amount the provider receives from the Primary plan, the Secondary plan and the Member shall not exceed the fee schedule of the Primary Plan. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan.
Primary Plan is an AC Plan and Secondary Plan is Fee Schedule Plan
If the provider is a network provider in the Secondary Plan, the Secondary Plan shall pay the lesser of: a) the difference between the amount of the billed charges for the Allowable Expenses and the
amount paid by the Primary Plan; or b) the amount the Secondary Plan would have paid if it had been the Primary Plan.
The Member shall only be liable for the copayment, deductible or coinsurance under the Secondary Plan if the Member has no liability for copayment, deductible or coinsurance under the Primary Plan and the total payments by both the primary and Secondary Plans are less than the provider’s billed charges. In no event shall the Member be responsible for any payment in excess of the copayment, coinsurance or deductible of the Secondary Plan.
Primary Plan is Fee Schedule Plan and Secondary Plan is an AC Plan
If the provider is a network provider in the Primary Plan, the Allowable Expense considered by the Secondary Plan shall be the fee schedule of the Primary Plan. The Secondary Plan shall pay the lesser of: a) The amount of any deductible, coinsurance or copayment required by the Primary Plan; or b) the amount the Secondary Plan would have paid if it had been the Primary Plan.
Primary Plan is Fee Schedule Plan and Secondary Plan is an AC Plan or Fee Schedule Plan
If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, the Secondary Plan shall pay benefits as if it were the Primary Plan.
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Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or an AC Plan If the Member receives services or supplies from a provider who is in the network of both the Primary Plan and the Secondary Plan, the Secondary Plan shall pay the lesser of:
a) The amount of any deductible, coinsurance or copayment required by the Primary Plan; or b) the amount the Secondary Plan would have paid if it had been the Primary Plan.
Primary Plan is Capitation Plan or Fee Schedule Plan or R&C Plan and Secondary Plan is Capitation Plan If the Member receives services or supplies from a provider who is in the network of the Secondary Plan, the Secondary Plan shall be liable to pay the capitation to the provider and shall not be liable to pay the deductible, coinsurance or copayment imposed by the Primary Plan. The Member shall not be liable to pay any deductible, coinsurance or copayments of either the Primary Plan or the Secondary Plan.
Primary Plan is an HMO or EPO and Secondary Plan is an HMO or EPO
If the Primary Plan is an HMO or EPO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Member receives from a non-network provider is not considered as urgent care or emergency care, but the provider is in the network of the Secondary Plan, the Secondary Plan shall pay benefits as if it were the Primary Plan. Except that the Primary Plan shall pay out-of-Network services, if any, authorized by the Primary Plan.
SERVICES FOR AUTOMOBILE RELATED INJURIES This section will be used to determine a Member’s coverage under the Contract when services are provided as a result of an automobile related Injury. Definitions "Automobile Related Injury" means bodily Injury sustained by a Member as a result of an accident: a) while occupying, entering, leaving or using an automobile; or b) as a pedestrian; caused by an automobile or by an object propelled by or from an automobile. "Allowable Expense" means a medically necessary, reasonable and customary item of expense covered at least in part as an eligible expense or eligible services by: a) the Contract; b) PIP; or c) OSAIC. "Eligible Services" means services provided for treatment of an Injury which is covered under the Contract without application of Cash Deductibles and Copayments, if any or Coinsurance. "Out-of-State Automobile Insurance Coverage” or "OSAIC" means any coverage for medical expenses under an automobile insurance policy other than PIP. OSAIC includes automobile insurance policies issued in another state or jurisdiction.
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"PIP" means personal injury protection coverage provided as part of an automobile insurance policy issued in New Jersey. PIP refers specifically to provisions for medical expense coverage.
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Determination of primary or secondary coverage. The Contract provides secondary coverage to PIP unless health coverage has been elected as primary coverage by or for the Member under the Contract. This election is made by the named insured under a PIP policy. Such election affects that person's family members who are not themselves named insureds under another automobile policy. The Contract may be primary for one Member, but not for another if the person has a separate automobile policy and has made different selection regarding primacy of health coverage. The Contract is secondary to OSAIC, unless the OSAIC contains provisions which make it secondary or excess to the Contractholder's plan. In that case the Contract will be primary. If there is a dispute as to which policy is primary, the Contract will pay benefits or provide services as if it were primary. Services the Contract will provide if it is primary to PIP or OSAIC. If the Contract is primary to PIP or OSAIC it will provide benefits for eligible expenses in accordance with its terms. The rules of the COORDINATION OF BENEFITS AND SERVICES section of the Contract will apply if: a) The Member is insured or covered for services under more than one insurance plan; and b) such insurance plans or HMO Contracts are primary to automobile insurance coverage. Benefits the Contract will pay if it is secondary to PIP or OSAIC. If the Contract is secondary to PIP or OSAIC the actual benefits payable will be the lesser of: a) the Allowable Expenses left uncovered after PIP or OSAIC has provided coverage after
applying Cash Deductibles and Copayments, or b) the equivalent value of services if the Contract had been primary.
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GENERAL PROVISIONS CLERICAL ERROR - MISSTATEMENTS Except as stated below, neither clerical error nor programming or systems error by the Contractholder, nor Us in keeping any records pertaining to coverage under the Contract, nor delays in making entries thereon, will invalidate coverage which would otherwise be in force, or continue coverage which would otherwise be validly terminated. Upon discovery of such error or delay, an appropriate adjustment of premiums will be made, as permitted by law. Exception: If an Employee contributed toward the premium payment and coverage continued in force beyond the date it should have been validly terminated as a result of such error or delay, the continued coverage will remain in effect through the end of the period for which the Employee contributed toward the premium payment and no premium adjustment will be made. Premium adjustments involving return of unearned premium to the Contractholder for such errors or delays will be made only if the Employee did not contribute toward the premium payment. Except as stated in the Premium Refunds section of the Premium Amounts provision of the Contract, such return of premium will be limited to the period of 12 months preceding the date of Our receipt of satisfactory evidence that such adjustments should be made. If the age or gender of an Employee is found to have been misstated, and the premiums are thereby affected, an equitable adjustment of premiums will be made. RETROACTIVE TERMINATION OF A MEMBER’S COVERAGE We will not retroactively terminate a Member’s coverage under the Contract after coverage under the Contract take effect unless the Member performs an act, practice, or omission that constitutes fraud, or unless the Member makes an intentional misrepresentation of material fact. In the event of such fraud or material misrepresentation We will provide at least 30 days advance written notice to each Member whose coverage will be retroactively terminated. If a Contractholder continues to pay the full premium for a Member who is no longer eligible to be covered the Contractholder may request a refund of premium as explained in the Premium Refunds provision of the Contract. If We refund premium to the Contractholder the refund will result in the retroactive termination of the Member’s coverage. The retroactive termination date will be the end of the period for which premium remains paid. Coverage will be retroactively terminated for the period for which premium is refunded. CONFORMITY WITH LAW Any provision of the Contract which, is in conflict with the laws of the State of New Jersey, or with Federal law, shall be construed and applied as if it were in full compliance with the minimum requirements of such State law or Federal law. CONTINUING RIGHTS Our failure to apply terms or conditions does not mean that We waive or give up any future rights under the Contract.
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INCONTESTABILITY OF THE CONTRACT There will be no contest of the validity of the Contract, except for not paying premiums, after it has been in force for two years. No statement in any application, except a fraudulent statement, made by the Contractholder or by a Member covered under the Contract shall be used in contesting the validity of his or her coverage or in denying benefits after such coverage has been in force for two years during the person's lifetime. Note: There is no time limit with respect to a contest in connection with fraudulent statements. LIMITATION ON ACTIONS No action at law or in equity shall be brought to recover on the Contract until 60 days after a Member files written proof of loss. No such action shall be brought more than three years after the end of the time within which proof of loss is required. OTHER RIGHTS We are only required to provide benefits to the extent stated in the Contract, its riders and attachments. We have no other liability. Services and supplies are to be provided in the most cost-effective manner practicable as Determined by Us. We reserve the right to use Our subsidiaries or appropriate employees or companies in administering the Contract. We reserve the right to modify or replace an erroneously issued Contract. Information in a Contractholder's application may not be used by Us to void the Contract or in any legal action unless the application or a duplicate of it is attached to the Contract or has been furnished to the Contractholder for attachment to the Contract. Information in a Member's application may not be used by Us to void his or her coverage under the Contract or in any legal action unless the application or a duplicate of it is attached to the Evidence of Coverage issued to a Member, or has been mailed to a Member for attachment to his or her Evidence of Coverage. PARTICIPATION REQUIREMENTS At least 75% of the Employees eligible for insurance must be enrolled for coverage. If an Employee eligible for insurance is not covered by this Contract because: a) the Employee is covered as a Dependent under a spouse's coverage, other than individual coverage; the Employee is covered under any fully-insured Health Benefits Plan issued by the same carrier offered by the Contractholder; b) the Employee is covered under Medicare; c) the Employee is covered under Medicaid or NJ FamilyCare; d) the Employee is covered under Tricare; or e) the Employee is covered under another group health benefits plan. AmeriHealth will count this person as being covered by this Contract for the purposes of satisfying participation requirements.
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PAYMENT OF PREMIUMS - GRACE PERIOD Premiums are to be paid by the Contractholder to Us. They are due on each Premium Due Date stated on the first page of the Contract. The Contractholder may pay each Premium other than the first within 31 days of the Premium Due Date. Those days are known as the grace period. The Contractholder is liable to pay Premiums to Us from the first day the Contract is in force. WORKERS' COMPENSATION The health benefits provided under the Contract are not in place of, and do not affect requirements for coverage by Workers' Compensation.
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CONTINUATION RIGHTS COORDINATION AMONG CONTINUATION RIGHTS SECTIONS As used in this section, COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985 as enacted, and later amended. A Member may be eligible to continue his or her group health benefits under this Contract’s COBRA CONTINUATION RIGHTS (CCR) section and under other continuation sections of this Contract at the same time. Continuation Under CCR and NEW JERSEY GROUP CONTINUATION RIGHTS (NJGCR): A Member who is eligible to continue his or her group health benefits under CCR is not eligible to continue under NJGCR. Continuation under CCR and NJGCR and NEW JERSEY CONTINUATION RIGHTS FOR OVER-AGE DEPENDENTS (NJCROD): A Dependent who has elected to continue his or her coverage under the group policy under which his or her parent is currently covered pursuant to NJCROD shall not be entitled to further continue coverage under CCR or NJGCR when continuation pursuant to NJCROD ends. Continuation Under CCR and any other continuation section of this Contract: If a Member elects to continue his or her group health benefits under this Contract's CCR or NJGCR, as applicable, and any other continuation other than NJCROD, the continuations: a) start at the same time; b) run concurrently; and c) end independently on their own terms. While covered under more than one continuation section, the Member: a) will not be entitled to duplicate benefits; and b) will not be subject to the premium requirements of more than one section at the same time. AN IMPORTANT NOTICE ABOUT CONTINUATION RIGHTS The following COBRA CONTINUATION RIGHTS section may not apply to the Employer's Contract. The Employee must contact his or her Employer to find out if: a) the Employer is subject to the COBRA CONTINUATION RIGHTS section in which
case; b) the section applies to the Employee. COBRA CONTINUATION RIGHTS (Generally applies to employer groups with 20 or more employees)
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Important Notice Under this section, "Qualified Continuee" means any person who, on the day before any event which would qualify him or her for continuation under this section, is covered for group health benefits under this Contract as: a) an active, covered Employee; b) the spouse of an active, covered Employee; or c) the Dependent child (except for the child of the Employee’s civil union partner) of an active,
covered Employee. Except as stated below, any person who becomes covered under this Contract during a continuation provided by this section is not a Qualified Continuee.
A civil union partner, and the child of an Employee’s civil union partner are never considered Qualified Continuees eligible to elect CCR. They may, however, be a Qualified Continuee eligible to elect under New Jersey Group Continuation Rights (NJGCR). Refer to the NJGCR section for more information. Exception: A child who is born to the covered Employee, or who is placed for adoption with the covered Employee during the continuation provided by this section is a Qualified Continuee. If An Employee's Group Health Benefits Ends If an Employee's group health benefits end due to his or her termination of employment or reduction of work hours, he or she may elect to continue such benefits for up to 18 months, unless he or she was terminated due to gross misconduct. A Qualified Continuee may elect to continue coverage under COBRA even if the Qualified Continuee: a) is covered under another group plan on or before the date of the COBRA election; or b) is entitled to Medicare on or before the date of the COBRA election. The continuation: a) may cover the Employee and any other Qualified Continuee; and b) is subject to the When Continuation Ends section. Extra Continuation for Disabled Qualified Continuees If a Qualified Continuee is determined to be disabled under Title II or Title XVI of the United States Social Security Act on the date his or her group health benefits would otherwise end due to the Employee's termination of employment or reduction of work hours or during the first 60 days of continuation coverage, he or she and any Qualified Continuee who is not disabled may elect to extend his or her 18 month continuation period above for up to an extra 11 months. To elect the extra 11 months of continuation, the Qualified Continuee or other person acting on his or her behalf must give the Employer written proof of Social Security's determination of his or her disability within 60 days measured from the latest of: a) the date on which the Social Security Administration issues the disability determination; b) the date the group health benefits would have otherwise ended; or c) the date the Qualified Continuee receives the notice of COBRA continuation rights. If, during this extra 11 month continuation period, the Qualified Continuee is determined to be no longer disabled under the Social Security Act, he or she must notify the Employer within 30 days of such determination, and continuation will end, as explained in the When Continuation Ends section.
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An additional 50% of the total premium charge also may be required from the Qualified Continuee by the Employer during this extra 11 month continuation period. If An Employee Dies While Insured If an Employee dies while insured, any Qualified Continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to 36 months, subject to the When Continuation Ends section. If An Employee's Marriage Ends If an Employee's marriage ends due to legal divorce or legal separation , any Qualified Continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to 36 months, subject to the When Continuation Ends section. If A Dependent Loses Eligibility If a Dependent child's group health benefits end due to his or her loss of dependent eligibility as defined in this Contract, other than the Employee's coverage ending, he or she may elect to continue such benefits. However, such Dependent child must be a Qualified Continuee. The continuation can last for up to 36 months, subject to When Continuation Ends. Concurrent Continuations If a Dependent elects to continue his or her group health benefits due to the Employee's termination of employment or reduction of work hours, the Dependent may elect to extend his or her 18 month continuation period to up to 36 months, if during the 18 month continuation period, either: a) the Dependent becomes eligible for 36 months of group health benefits due to any of the
reasons stated above; or b) the Employee becomes entitled to Medicare. The 36 month continuation period starts on the date the 18 month continuation period started, and the two continuation periods will be deemed to have run concurrently. Special Medicare Rule Except as stated below, the “special rule” applies to Dependents of an Employee when the Employee becomes entitled to Medicare prior to termination of employment or reduction in work hours. The continuation period for a Dependent upon the Employee’s subsequent termination of employment or reduction in work hours will be the longer of the following: a) 18 months from the date of the Employee’s termination of employment or reduction in work
hours; or b) 36 months from the date of the Employee’s earlier entitlement to Medicare. Exception: If the Employee becomes entitled to Medicare more than 18 months prior to termination of employment or reduction in work hours, this “special rule” will not apply. The Qualified Continuee's Responsibilities A person eligible for continuation under this section must notify the Employer, in writing, of: a) the legal divorce or legal separation of the Employee from his or her spouse; or b) the loss of dependent eligibility, as defined in this Contract, of an insured Dependent child. Such notice must be given to the Employer within 60 days of either of these events.
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The Employer's Responsibilities The Employer must notify the Qualified Continuee, in writing, of: a) his or her right to continue this Contract's group health benefits; b) the monthly premium he or she must pay to continue such benefits; and c) the times and manner in which such monthly payments must be made. Such written notice must be given to the Qualified Continuee within 44 days of: a) the date a Qualified Continuee's group health benefits would otherwise end due to the
Employee's death or the Employee's termination of employment or reduction of work hours; or
b) the date a Qualified Continuee notifies the Employer, in writing, of the Employee's legal divorce or legal separation from his or her spouse, or the loss of dependent eligibility of an insured Dependent child.
The Employer's Liability The Employer will be liable for the Qualified Continuee's continued group health benefits to the same extent as, and in place of, AmeriHealth, if: a) the Employer fails to remit a Qualified Continuee's timely premium payment to AmeriHealth
on time, thereby causing the Qualified Continuee's continued group health benefits to end; or
b) the Employer fails to notify the Qualified Continuee of his or her continuation rights, as described above.
Election of Continuation To continue his or her group health benefits, the Qualified Continuee must give the Employer written notice that he or she elects to continue. An election by a minor Dependent Child can be made by the Dependent Child’s parent or legal guardian. This must be done within 60 days of the date a Qualified Continuee receives notice of his or her continuation rights from the Employer as described above. And the Qualified Continuee must pay the first month's premium in a timely manner. The subsequent premiums must be paid to the Employer, by the Qualified Continuee, in advance, at the times and in the manner specified by the Employer. No further notice of when premiums are due will be given. The monthly premium will be the total rate which would have been charged for the group health benefits had the Qualified Continuee stayed insured under this Contract on a regular basis. It includes any amount that would have been paid by the Employer. Except as explained in the Extra Continuation for Disabled Qualified Continuees section, an additional charge of two percent of the total premium charge may also be required by the Employer. If the Qualified Continuee fails to give the Employer notice of his or her intent to continue, or fails to pay any required premiums in a timely manner, he or she waives his or her continuation rights. Grace in Payment of Premiums A Qualified Continuee's premium payment is timely if, with respect to the first payment after the Qualified Continuee elects to continue, such payment is made no later than 45 days after such election. In all other cases, such premium payment is timely if it is made within 31 days of the specified date.
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If timely payment is made to the plan in an amount that is not significantly less than the amount the Employer requires to be paid for the period of coverage, then the amount paid is deemed to satisfy the Employer’s requirement for the amount that must be paid, unless the plan notifies the Qualified Continuee of the amount of the deficiency and grants an additional 30 days for payment of the deficiency to be made. An amount is not significantly less than the amount the Employer requires to be paid for a period of coverage if and only if the shortfall is no greater than the lesser of the following two amounts: a) Fifty dollars (or such other amount as the Commissioner may provide in a revenue ruling,
notice, or other guidance published in the Internal Revenue Code Bulletin); or b) Ten percent of the amount the plan requires to be paid. Payment is considered as made on the date on which it is sent to the Employer. When Continuation Ends A Qualified Continuee's continued group health benefits end on the first of the following: a) with respect to continuation upon the Employee's termination of employment or reduction of
work hours, the end of the 18 month period which starts on the date the group health benefits would otherwise end;
b) with respect to a Qualified Continuee who has elected an additional 11 months of continuation due to his or her own disability or the disability of a family member, the earlier of:
the end of the 29 month period which starts on the date the group health benefits would otherwise end; or
the first day of the month which coincides with or next follows the date which is 30 days after the date on which a final determination is made that a disabled Qualified Continuee is no longer disabled under Title II or Title XVI of the United States Social Security Act; c) with respect to continuation upon the Employee's death, the Employee's legal divorce or
legal separation or the end of an insured Dependent's eligibility, the end of the 36 month period which starts on the date the group health benefits would otherwise end;
d) with respect to a Dependent whose continuation is extended due to the Employee's entitlement to Medicare, the end of the 36 month period which starts on the date the group health benefits would otherwise end;
e) the date this Contract ends; f) the end of the period for which the last premium payment is made; g) the date he or she becomes covered under any other group health plan which contains no
limitation or exclusion with respect to any pre-existing condition of the Qualified Continuee or contains a pre-existing conditions limitation or exclusion that is eliminated through the Qualified Continuee’s total period of creditable coverage.;
h) the date he or she becomes entitled to Medicare; i) termination of a Qualified Continuee for cause (e.g. submission of a fraudulent claim) on the
same basis that the Employer terminates coverage of an active employee for cause.
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NEW JERSEY GROUP CONTINUATION RIGHTS (NJGCR) Important Notice Except as stated below, under this section, "Qualified Continuee" means any person who, on the day before any event which would qualify him or her for continuation under this section, is covered for group health benefits under this Contract as:
a) a full-time covered Employee; b) the spouse of a full-time covered Employee; or c) the Dependent child of a full-time covered Employee.
Exception: A Newly Acquired Dependent, where birth, adoption, or marriage occurs after the Qualifying Event is also a “Qualified Continuee” for purposes of being included under the Employee’s continuation coverage. If An Employee's Group Health Benefits Ends If an Employee's group health benefits end due to his or her termination of employment or reduction of work hours to fewer than 25 hours per week, he or she may elect to continue such benefits for up to 18 months, unless he or she was terminated for cause. The Employee’s spouse and Dependent children may elect to continue benefits even if the Employee does not elect continuation for himself or herself. A Qualified Continuee may elect to continue coverage under NJGCR even if the Qualified Continuee: a) is covered under another group plan on or before the date of the NJGCR election; or b) is entitled to Medicare on or before the date of the NJGCR election. The continuation: a) may cover the Employee and/or any other Qualified Continuee; and b) is subject to the When Continuation Ends section. Extra Continuation for Disabled Qualified Continuees If a former Employee who is a Qualified Continuee is determined to be disabled under Title II or Title XVI of the United States Social Security Act on the date his or her group health benefits would otherwise end due to the termination of employment or reduction of work hours to fewer than 25 hours per week or during the first 60 days of continuation coverage, he or she may elect to extend his or her 18-month continuation period for himself or herself and any Dependents who are Qualified Continuees for up to an extra 11 months. To elect the extra 11 months of continuation, the Qualified Continuee must give AmeriHealth written proof of Social Security's determination of his or her disability before the earlier of: a) the end of the 18 month continuation period; and b) 60 days after the date the Qualified Continuee is determined to be disabled. If, during this extra 11 month continuation period, the Qualified Continuee is determined to be no longer disabled under the Social Security Act, he or she must notify AmeriHealth within 31 days of such determination, and continuation will end, as explained in the When Continuation Ends section.
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An additional 50% of the total premium charge also may be required from the Qualified Continuee by the Employer during this extra 11 month continuation period. If An Employee Dies While Insured If an Employee dies while insured, any Qualified Continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to 36 months, subject to the When Continuation Ends section. If An Employee's Marriage or Civil Union Ends If an Employee's marriage ends due to legal divorce or legal separation or dissolution of the civil union, any Qualified Continuee whose group health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to 36 months, subject to the When Continuation Ends section. If A Dependent Loses Eligibility If a Dependent child's group health benefits end due to his or her loss of dependent eligibility as defined in this Contract, other than the Employee's coverage ending, he or she may elect to continue such benefits for up to 36 months, subject to When Continuation Ends. The Employer's Responsibilities Upon loss of coverage due to termination of employment or reduction in work hours, the Employer must notify the former employee in writing, of: a) his or her right to continue this Contract's group health benefits; b) the monthly premium he or she must pay to continue such benefits; and c) the times and manner in which such monthly payments must be made. Upon being advised of the death of the Employee, divorce, dissolution of the civil union, or Dependent child’s loss of eligibility, the Employer should notify the Qualified Continuee in writing, of: a) his or her right to continue this Contract's group health benefits; b) the monthly premium he or she must pay to continue such benefits; and c) the times and manner in which such monthly payments must be made. Election of Continuation To continue his or her group health benefits, the Qualified Continuee must give the Employer written notice that he or she elects to continue. An election by a minor Dependent Child can be made by the Dependent Child’s parent or legal guardian. This must be done within 30 days of the date coverage ends. The first month's premium must be paid within 30 days of the date the Qualified Continuee elects continued coverage. The subsequent premiums must be paid to the Employer, by the Qualified Continuee, in advance, at the times and in the manner specified by the Employer. The monthly premium will be the total rate which would have been charged for the group health benefits had the Qualified Continuee stayed insured under this Contract on a regular basis. It includes any amount that would have been paid by the Employer. Except as explained in the Extra Continuation for Disabled Qualified Continuees section, an additional charge of two percent of the total premium charge may also be required by the Employer.
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If the Qualified Continuee does not give the Employer notice of his or her intent to continue coverage, or fails to pay any required premiums in a timely manner, he or she waives his or her continuation rights. Grace in Payment of Premiums A Qualified Continuee's premium payment is timely if, with respect to the first payment after the Qualified Continuee elects to continue, such payment is made no later than 30 days after such election. In all other cases, such premium payment is timely if it is made within 31 days of the date it is due. The Continued Coverage The continued coverage shall be identical to the coverage provided to similarly situated active Employees and their Dependents under the Employer’s plan. If coverage is modified for any group of similarly situated active Employees and their Dependents, the coverage for Qualified Continuees shall also be modified in the same manner. Evidence of insurability is not required for the continued coverage. When Continuation Ends A Qualified Continuee's continued group health benefits end on the first of the following:
a) with respect to continuation upon the Employee's termination of employment or reduction of work hours, the end of the 18 month period which starts on the date the group health benefits would otherwise end;
b) with respect to a Qualified Continuee who has elected an additional 11 months of continuation due to his or her own disability, the end of the 29 month period which starts on the date the group health benefits would otherwise end. However, if the Qualified Continuee is no longer disabled, coverage ends on the later of:
the end of the 18-month period; or
the first day of the month that begins more than 31 days after the date on which a final determination is made that a disabled Qualified Continuee is no longer disabled under Title II or Title XVI of the United States Social Security Act;
c) with respect to continuation upon the Employee's death, the Employee's legal divorce or legal separation, dissolution of the civil union, or the end of an insured Dependent's eligibility, the end of the 36 month period which starts on the date the group health benefits would otherwise end;
d) the date the Employer ceases to provide any health benefits plan to any active Employee or Qualified Continuee;
e) the end of the period for which the last premium payment is made; f) the date he or she first becomes covered under any other group health benefits plan, as
an employee or otherwise, which contains no limitation or exclusion with respect to any pre-existing condition of the Qualified Continuee; or
g) the date he or she first becomes entitled to Medicare.
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NEW JERSEY CONTINUATION RIGHTS FOR OVER-AGE DEPENDENTS (Applies to all size groups): As used in this provision, “Over-Age Dependent” means an Employee’s child by blood or law who: a) has reached the limiting age under the group plan, but is less than 31 years of age; b) is not married or in a civil union partnership; c) has no Dependents of his or her own; d) is either a resident of New Jersey or is enrolled as a full-time student at an Accredited
School; and e) is not covered under any other group or individual health benefits plan, group health plan,
church plan or health benefits plan, and is not entitled to Medicare on the date the Over-Age Dependent continuation coverage begins.
If A Dependent Is Over the Limiting Age for Dependent Coverage If a Dependent Child is over the age 26 limiting age for dependent coverage and: a) the Dependent child's group health benefits are ending or have ended due to his or her
attainment of age 26; or b) the Dependent child has proof of prior creditable coverage or receipt of benefits, he or she may elect to be covered under the Employer’s plan until his or her 31st birthday, subject to the Conditions for Election, Election of Continuation and When Continuation Ends sections below. Conditions for Election An Over-Age Dependent is only entitled to make an election for continued coverage if all of the following conditions are met. a) The Over-Age Dependent must provide evidence of prior creditable coverage or receipt of
benefits under a group or individual health benefits plan, group health plan, church plan or health benefits plan or Medicare. Such prior coverage must have been in effect at some time prior to making an election for this Over-Age Dependent coverage.
b) A parent of an Over-Age Dependent must be enrolled as having elected Dependent coverage at the time the Over-Age Dependent elects continued coverage. Except, if the Employee has no other Dependents, or has a Spouse who is covered elsewhere, the Over-Age Dependent may nevertheless select continued coverage.
Election of Continuation To maintain continuous group health benefits, the Over-Age Dependent must make written election to Us within 30 days of the date the Over-Age Dependent attains age 26. The effective date of the continued coverage will be the date the Dependent would otherwise lose coverage due to attainment of age 26 provided written notice of the election of coverage is given and the first premium is paid.
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For a Dependent who was not covered on the date he or she reached the limiting age, the written election may be made within 30 days of the date the Over-Age Dependent attains age 26. The effective date of coverage will be the date the Dependent attains age 26 provided written notice of the election of coverage is given and the first premium is paid within such 30-day period. For a person who did not qualify as an Over-Age Dependent because he or she failed to meet all the requirements of an Over-Age Dependent, but who subsequently meets all of the requirements for an Over-Age Dependent, written election may be made within 30 days of the date the person meets all of the requirements for an Over-Age Dependent. If the election is not made within the 30-day periods described above an eligible Over-Age Dependent may subsequently enroll during an Employee Open Enrollment Period. Payment of Premium The first month's premium must be paid within the 30-day election period provided above. If the election is made during the Employee Open Enrollment Period the first premium must be paid before coverage takes effect on the Contractholder’s Anniversary Date following the Employee Open Enrollment Period. The Over-Age Dependent must pay subsequent premiums monthly, in advance, at the times and in the manner specified by AmeriHealth and will be remitted by the Employer. Grace in Payment of Premiums An Over-Age Dependent’s premium payment is timely if, with respect to all payments other than the first payment such premium payment is made within 30 days of the date it is due. The Continued Coverage The continued coverage shall be identical to the coverage provided to the Over-Age Dependent’s parent who is covered as an Employee under the Contract. If coverage is modified for Dependents who are under the limiting age, the coverage for Over-Age Dependents shall also be modified in the same manner. When Continuation Ends An Over-Age Dependent’s continued group health benefits end on the first of the following: a) the date the Over-Age Dependent:
1. attains age 31 2. marries or enters into a civil union partnership; 3. acquires a Dependent; 4. is no longer either a resident of New Jersey or enrolled as a full-time student at
an Accredited School; or 5. becomes covered under any other group or individual health benefits plan, group
health plan, church plan or health benefits plan, or becomes entitled to Medicare b) the end of the period for which premium has been paid for the Over-Age Dependent, subject
to the Grace Period for such payment; c) the date the Policy ceases to provide coverage to the Over-Age Dependent’s parent who is
the Employee under the Policy. d) The date the Policy under which the Over-Age Dependent elected to continue coverage is
amended to delete coverage for Dependents.
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e) The date the Over-Age Dependent’s parent who is covered as an Employee under the Policy waives Dependent coverage. Except, if the Employee has no other Dependents, the Over-Age Dependent’s coverage will not end as a result of the Employee waiving Dependent coverage.
A TOTALLY DISABLED EMPLOYEE'S RIGHT TO CONTINUE GROUP HEALTH BENEFITS If An Employee is Totally Disabled An Employee who is Totally Disabled and whose group health benefits end because his or her active employment or membership in an eligible class ends due to that disability, can elect to continue his or her group health benefits. But he or she must have been covered by the Contract for at least three months immediately prior to the date his or her group health benefits ends. The continuation can cover the Employee, and at his or her option, his or her then covered Dependents. How And When To Continue Coverage To continue group health benefits, the Employee must give the Employer written notice that he or she elects to continue such benefits. And he or she must pay the first month's premium. This must be done within 31 days of the date his or her coverage under the Contract would otherwise end. Subsequent premiums must be paid to the Employer monthly, in advance, at the times and in the manner specified by the Employer. The monthly premium the Employee must pay will be the total rate charged for an active Full-Time Employee, covered under the Contract on a regular basis, on the date each payment is due. It includes any amount which would have been paid by the Employer. We will consider the Employee's failure to give notice or to pay any required premium as a waiver of the Employee's continuation rights. If the Employer fails, after the timely receipt of the Employee's payment, to pay Us on behalf of such Employee, thereby causing the Employee's coverage to end; then such Employer will be liable for the Employee's benefits, to the same extent as, and in place of, Us. When This Continuation Ends These continued group health benefits end on the first of the following: a) the end of the period for which the last payment is made, if the Employee stops paying. b) the date the Member becomes employed and eligible or covered for similar benefits by
another group plan, whether it be an insured or uninsured plan; c) the date the Contract ends or is amended to end for the class of Employees to which the
Employee belonged; or d) with respect to a Dependent, the date he or she stops being an eligible Dependent as
defined in the Contract.
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AN EMPLOYEE'S RIGHT TO CONTINUE GROUP HEALTH BENEFITS DURING A FAMILY LEAVE OF ABSENCE Important Notice This section may not apply to an Employer's plan. The Employee must contact his or her Employer to find out if: a) the Employer must allow for a leave of absence under Federal law in which case; b) the section applies to the Employee. If An Employee's Group Health Coverage Ends Group health coverage may end for an Employee because he or she ceases Full-Time work due to an approved leave of absence. Such leave of absence must have been granted to allow the Employee to care for a sick family member or after the birth or adoption of a child. If so, his or her medical care coverage will be continued. Dependents' coverage may also be continued. The Employee will be required to pay the same share of premium as before the leave of absence. When Continuation Ends Coverage may continue until the earliest of: a) the date the Employee returns to Full-Time work; b) the end of a total period of 12 weeks in any 12 month period; c) the date on which the Employee's coverage would have ended had the Employee not been
on leave; or d) the end of the period for which the premium has been paid. A DEPENDENT'S RIGHT TO CONTINUE GROUP HEALTH BENEFITS If an Employee dies, any of his or her Dependents who were covered under the Contract may elect to continue coverage. Subject to the payment of the required premium, coverage may be continued until the earlier of: a) 180 days following the date of the Employee's death; or b) the date the Dependent is no longer eligible under the terms of the Contract.
CONVERSION RIGHTS FOR DIVORCED SPOUSES IF AN EMPLOYEE'S MARRIAGE OR CIVIL UNION ENDS If an Employee's marriage ends by legal divorce or annulment or the employee’s civil union is dissolved, the group health coverage for his or her former spouse ends. The former spouse may convert to an individual contract during the conversion period. The former spouse may cover under his or her individual contract any of his or her Dependent children who were covered under the Contract on the date the group health coverage ends. See Exceptions below. Exceptions No former spouse may use this conversion right: a) if he or she is eligible for Medicare;
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b) if it would cause him or her to be excessively covered; This may happen if the spouse is covered or eligible for coverage providing similar benefits provided by any other plan, insured or not insured. We will Determine if excessive coverage exists using Our standards for excessive coverage. or
c) if he or she permanently relocates outside the Service Area. HOW AND WHEN TO CONVERT The conversion period means the 31 days after the date group health coverage ends. The former spouse must apply for the individual contract in writing and pay the first premium for such contract during the conversion period. Evidence of good health will not be required. THE CONVERTED CONTRACT The individual contract will provide the medical benefits that We are required to offer. The individual contract will take effect on the day after group health coverage under the Contract ends. After group health coverage under the Contract ends, the former spouse and any children covered under the individual contract may still receive benefits under the Contract. If so, benefits to be paid under the individual contract, if any, will be reduced by the amount paid or the reasonable cash value of services provided under the Contract.
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MEDICARE AS SECONDARY PAYOR IMPORTANT NOTICE The following sections regarding Medicare may not apply to the Employer's Contract. The Employee must contact his or her Employer to find out if the Employer is subject to Medicare as Secondary Payor rules. If the Employer is subject to such rules, this Medicare as Secondary Payor section applies to the Employee. If the Employer is NOT subject to such rules, this Medicare as Secondary Payor section does not apply to the Employee, in which case, Medicare will be the primary health plan and the Contract will be the secondary health plan for Members who are eligible for Medicare. Benefits will be payable as specified in the COORDINATION OF BENEFITS AND SERVICES section of the Contract. The following provisions explain how the Contract’s group health benefits interact with the benefits available under Medicare as Secondary Payor rules. A Member may be eligible for Medicare by reason of age, disability, or End Stage Renal Disease. Different rules apply to each type of Medicare eligibility, as explained below. With respect to the following provisions: a) "Medicare" when used above, means Part A and B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time. b) A Member is considered to be eligible for Medicare by reason of age from the first day of the month during which he or she reaches age 65. However, if the Member is born on the first day of a month, he or she is considered to be eligible for Medicare from the first day of the month which is immediately prior to his or her 65th birthday. c) A "primary" health plan pays benefits for a Member’s Covered Service or Supply or Covered Charge first, ignoring what the Member’s "secondary" plan pays. A "secondary" health plan then pays the remaining unpaid allowable expenses. See the COORDINATION OF BENEFITS AND SERVICES section for a definition of "allowable expense". MEDICARE ELIGIBILITY BY REASON OF AGE (Generally applies to employer groups with 20 or more employees) Applicability This section applies to an Employee or his or her covered spouse who is eligible for Medicare by reason of age. This section does not apply to an insured civil union partner who is eligible for Medicare by reason of age. Under this section, such an Employee or covered spouse is referred to as a "Medicare eligible". This section does not apply to: a) a Member, other than an Employee or covered spouse b) an Employee or covered spouse who is under age 65, or c) a Member who is eligible for Medicare solely on the basis of End Stage Renal Disease.
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When An Employee or Covered Spouse Becomes Eligible For Medicare When an Employee or covered spouse becomes eligible for Medicare by reason of age, he or she must choose one of the two options below. Option (A) - The Medicare eligible may choose the Contract as his or her primary health plan. If he or she does, Medicare will be his or her secondary health plan. See the When The Contract is Primary section below, for details. Option (B) - The Medicare eligible may choose Medicare as his or her primary health plan. If he or she does, group health benefits under the Contract will end. See the When Medicare is Primary section below, for details. If the Medicare eligible fails to choose either option when he or she becomes eligible for Medicare by reason of age, We will provide services and supplies and pay benefits as if he or she had' chosen Option (A). When the Contract is primary When a Medicare eligible chooses the Contract as his or her primary health plan, if he or she incurs a Covered Service and Supply or Covered Charge for which benefits are payable under both the Contract and Medicare, the Contract is considered primary. The Contract provides services and supplies and pays first, ignoring Medicare. Medicare is considered the secondary plan. When Medicare is primary If a Medicare eligible chooses Medicare as his or her primary health plan, he or she will no longer be covered for such benefits by the Contract. Coverage under this Contact will end on the date the Medicare eligible elects Medicare as his or her primary health plan. A Medicare eligible who elects Medicare as his or her primary health plan, may later change such election, and choose the Contract as his or her primary health plan. MEDICARE ELIGIBILITY BY REASON OF DISABILITY (Generally applies to employer groups with 100 or more employees) Applicability This section applies to a Member who is
a) under age 65 except for the Employee’s civil union partner or the child of the Employee’s civil union partner and
b) eligible for Medicare by reason of disability or c) a Member who is the Employee’s civil union partner or the child of the Employee’s civil
union partner. Under this section, such Member is referred to as a "disabled Medicare eligible". This section does not apply to: a) a Member who is eligible for Medicare by reason of age; or b) a Member who is eligible for Medicare solely on the basis of End Stage Renal Disease.
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When A Member Becomes Eligible For Medicare When a Member becomes eligible for Medicare by reason of disability, the Contract is the primary plan. The Contract is the secondary plan. If a Member is eligible for Medicare by reason of disability, he or she must be covered by both Parts A and B. Benefits will be payable as specified in the COORDINATION OF BENEFITS AND SERVICES section of the Contract. MEDICARE ELIGIBILITY BY REASON OF END STAGE RENAL DISEASE (Applies to all employer groups) Applicability This section applies to a Member who is eligible for Medicare on the basis of End Stage Renal Disease (ESRD). Under this section such Member is referred to as a "ESRD Medicare eligible". This section does not apply to a Member who is eligible for Medicare by reason of disability. When A Member Becomes Eligible For Medicare Due to ESRD When a Member becomes eligible for Medicare solely on the basis of ESRD, for a period of up to 30 consecutive months, if he or she incurs a charge for the treatment of ESRD for which services and supplies are provided or benefits are payable under both the Contract and Medicare, the Contract is considered primary. The Contract provides services and supplies and pays first, ignoring Medicare. Medicare is considered the secondary plan. This 30 month period begins on the earlier of: a) the first day of the month during which a regular course of renal dialysis starts; and b) with respect to a ESRD Medicare eligible who receives a kidney transplant, the first day of the month during which such Member becomes eligible for Medicare. After the 30 month period described above ends, if a ESRD Medicare eligible incurs a charge for which services and supplies are provided and benefits are payable under both the Contract and Medicare, Medicare is the primary plan. The Contract is the secondary plan. If a Member is eligible for Medicare on the basis of ESRD, he or she must be covered by both Parts A and B. Benefits will be payable as specified in the COORDINATION OF BENEFITS AND SERVICES section of the Contract.
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STATEMENT OF ERISA RIGHTS The following Statement may not apply to the Employer's Contract. The Employee must contact his or her Employer to find out if the Employer is subject to these ERISA requirements As a plan participant, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the plan administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefit Security Administration. Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies. Receive a summary of the plan’s annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights, if COBRA is applicable to your plan. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
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Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or medical support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance With Your Questions If you have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Employee Benefit Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefit Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefit Security Administration.
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AMERIHEALTH HMO, INC.
AMENDMENT
BENEFITS UNDER THE GUEST ADVANTAGE PROGRAMsm
The Evidence of Coverage includes the following provisions by attachment of this Amendment. Except as stated below, nothing in this Amendment changes or affects any other items of the Evidence of Coverage.
In addition to the benefits already described in the Evidence of Coverage, the Member may apply to be a Guest Advantage Member to receive benefits under the Guest Advantage Program. Under this Program, a Member that applies to become a Guest Advantage Member has benefits for Covered Services and Supplies received while temporarily outside the Service Area. Guest Advantage benefits are only available when Members enrolled in the Guest Advantage Program utilize PHCS/Multiplan, Inc. Providers who are located within forty-five (45) miles of the temporary Member address supplied on the Guest Advantage application. Covered Services and Supplies for the Guest Advantage Program are the same Covered Services and Supplies a Member has when care is provided in the Network by Network Providers. Pre-Certification is the responsibility of the Guest Advantage Member. Pre-Certification is required for certain Covered Services and Supplies. Benefits are subject to the Evidence of Coverage’s SCHEDULE OF COVERED SERVICES AND SUPPLIES. Emergency and Out-of-Area Urgent Care are NOT subject to this Rider. Such care is always covered as if Network Providers provided the Covered Services and Supplies in the Service Area. Please see the Section on Emergency and Out-of-Area Urgent Care in the Evidence of Coverage for terms and conditions regarding Emergency and Out-of-Area Urgent Care. Definitions For the purpose of the Guest Advantage Program the following terms are made a part of the Definitions section of the Evidence of Coverage. The definitions contained in this Rider apply to the Guest Advantage Program and may differ from the definitions contained in the Evidence of Coverage:
COINSURANCE - that portion of the charge for the Covered Services and Supplies that the Guest Advantage Member will be required to pay which is consistent with any coinsurance payable for Network services under AmeriHealth’s benefit plan. Coinsurance is a percentage of the provider’s charge for the Covered Services or Supplies or it may be a flat dollar amount. The Network Coinsurance percentage, if any, is listed in the Evidence of Coverage’s SCHEDULE OF COVERED SERVICES AND SUPPLIES.
GUEST ADVANTAGE MEMBER - a Member who has enrolled in the Guest Advantage Program. The period of time the Member is in the Guest Advantage Program will be part of the application process, but will be no more than one (1) year. The effective date of coverage will also be determined during the application process. After that period of time has expired, the Member must again meet the eligibility requirements and re-enroll as a Guest Advantage Member to continue to be covered for Guest Advantage Program benefits. If the Member no longer qualifies as a Guest Advantage Member, and does not return to AmeriHealth’s Service Area, he/she will be disenrolled from the plan. The Guest Advantage Program Member coverage is located within the fifty (50) states of the United States and the
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District of Columbia and does not provide for international coverage.
GUEST ADVANTAGE PROGRAM - a program that provides benefits for covered services to Members who apply for and are accepted as Guest Advantage Members in the Program while outside AmeriHealth’s Service Area. The Guest Advantage Program provides Members with access to Providers who are part of the PHCS/Multiplan, Inc. network, with such Providers being within forty-five (45) miles of the temporary Member address supplied on the Guest Advantage application. The minimum period of time the Member expects to be outside the Service Area to apply for coverage as a Guest Advantage Member is ninety (90) consecutive days. Please see the section “Temporary Return to the Service Area” contained in this Rider for terms and conditions related to coverage when a Member temporarily returns to the Service Area. The Guest Advantage Program provides the same covered services available to the Member from Network Providers, subject to the Guest Advantage Member obtaining Pre-Certification for certain of the services. This Program provides benefits for a limited period of time.
PRE-CERTIFICATION (PRE-CERTIFIED) – the process whereby services are reviewed and approved by AmeriHealth prior to being provided to the Guest Advantage Member. Pre-Certification is the responsibility of the Guest Advantage Member. Pre-Certification is required for certain Covered Services and Supplies. No Pre-Certification is required fpr Inpatient Maternity admissions. The purpose of this review is to determine the services and supplies are Medically Necessary and Appropriate, including length of stay when applicable. A Guest Advantage Member is required to notify AmeriHealth of any service that requires Pre-Certification. The Guest Advantage Member must call the Pre-Certification telephone number shown on the ID Card in order to comply with this notification requirement. Services requiring Pre-Certification that have not been Pre-Certified will result in a reduction of 50% of the benefits otherwise payable.
A Guest Advantage Member Must Obtain Pre-Certification For Certain Services Pre-Certification is required for the same Covered Services and Supplies that the Primary Care Physician or Specialist is required to have Preapproved by the AmeriHealth when the service is provided in the Service Area. The Member will need to call for Pre-Certification at least five (5) working days prior to the scheduled service that requires Pre-Certification. To obtain a list of Covered Services that require Pre-certification, please log onto www.amerihealthnj.com or call the telephone number that is listed on your ID Card. Services that have received preapproval from the Member’s PCP prior to acceptance under the Guest Advantage Program will not be considered Pre-Certified. No Pre-Certification is required for Inpatient Maternity admissions. The Guest Advantage Member must call the Pre-Certification telephone number shown on the ID Card in order to comply with this notification requirement. Penalty When Pre-Certification is not obtained by the Guest Advantage Member Services that require Pre-Certification that have not been Pre-Certified by the Guest Advantage Member will result in a benefit reduction equal to 50% of the benefits otherwise payable.
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Emergency and Out-of-Area Urgent Care are NOT subject to a Pre-Certification requirement. Such care is always covered as if Network Providers provided the Covered Services and Supplies in the Service Area. Please see the Emergency and Out-of-Area Urgent Care section in the Evidence of Coverage for terms and conditions regarding Emergency and Out-of-Area Urgent Care. How To Request Reimbursement For Covered Services and Supplies as a Guest Advantage Member The following information describes the process for a Guest Advantage Member in order to request reimbursement for Covered Services and Supplies received as a Guest Advantage Member:
The Provider may collect the Copayment that appears on the ID Card for the visit(s)/service(s) or the Guest Advantage Member may be asked to pay the cost for the visit(s)/services(s) when provided.
If the Provider does not agree to bill AmeriHealth, the Guest Advantage Member should send the itemized bill, along with proof of payment, to AmeriHealth.
The Guest Advantage Member should be sure to include his/her full name, address and the Identification Number that appears on his/her ID Card.
No claim form is required. All requests for reimbursement should be mailed to the address on the back of the ID card. AmeriHealth will send a check for the amount of the bill minus the Member’s Copayment(s) and/or Coinsurance.
Requests for reimbursement submitted to AmeriHealth as described above will be subject to the following actions by AmeriHealth:
AmeriHealth will pay benefits for Covered Services and Supplies within thirty (30) days of receipt of the request for reimbursement, if it is submitted electronically, and forty (40) days, if submitted by paper. This is true unless AmeriHealth contests all or a portion of the itemized charges.
If AmeriHealth contests the itemized charges or a portion of them, the uncontested portion shall be paid within the time limits set forth above. If additional information is needed to finalize a request for reimbursement, such as medical records, AmeriHealth will notify the provider directly.
AmeriHealth will pay or deny all or a portion of a contested request for reimbursement within the time limits set forth above following AmeriHealth’s receipt of the additional information requested from the provider.
Payment by AmeriHealth will be considered to be made on the date the instrument representing payment was placed in the United States mail in a properly addressed, postpaid envelope or, if not so posted, on the date of delivery.
AmeriHealth will include with any overdue payment simple interest at the rate of ten percent (10%) per year.
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How Does the Guest Advantage Program Work? A Member may apply to be accepted as a Guest Advantage Member when outside the AmeriHealth’s Service Area. To be eligible for the Program the Member must be:
An Employee temporarily traveling outside AmeriHealth’s Service Area for at least ninety (90) days, but no more than one hundred eighty (180) days;
A Dependent student attending a school outside AmeriHealth’s Service Area for more than ninety (90) days; or
A Dependent living apart from the Subscriber and outside AmeriHealth’s Service Area for more than ninety (90) days and the employee has been court ordered to provide coverage.
A Member may request an application either on-line or by calling Customer Service. The application can be either mailed or submitted on-line. When do Benefits under the Guest Advantage Program begin and how long are they available? Guest Advantage benefits will start at least two weeks after the application has been received. The effective date will be determined by the plan. Benefits under the Program are available for up to one year.
What happens when the Guest Advantage Member returns to AmeriHealth’s Service Area?
Temporary Return to the Service Area: When the Guest Advantage Member temporarily returns to AmeriHealth’s Service Area and requires medical treatment, AmeriHealth still considers the person to be a Guest Advantage Member; however, the rules and procedures that apply for Referrals as described in the Member’s benefit description material for services obtained within the Network will apply. If a Member sees a Network Provider, there is no action required by the Member.
If a Member sees a Non-Network Provider, the Member will need to obtain a Pre-Certification.
Permanent Return to the Service Area:
If a Member returns to the Service Area on the specified end date, no action is required by the Member.
If a Member returns to the Service Area before the pre-specified end date, the Member is required to contact the AmeriHealth’s Customer Service Department.
NOTE: Because a Member’s Primary Care Physician can give advice and provide recommendations about health care services that a Member may need while traveling, the Member is encouraged to receive routine or planned care, including elective procedures and surgeries, prior to leaving home.
What happens if the Member has a Complaint or does not agree with the way benefits have been determined under the Guest Advantage Program? A Member with a problem or concern about the services or benefits received while in the Guest Advantage Program has the same right to file a Complaint or to Appeal a coverage decision as
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when in AmeriHealth’s Service Area and receiving care from Network Providers. AmeriHealth has responsibility for benefits provided under the Guest Advantage Program. Refer to the APPEAL PROCEDURES in the Evidence of Coverage. When filing a Complaint or Appeal involving services provided outside AmeriHealth’s Service Area under the Guest Advantage Program, the Member will need to provide the dates of service and provider information pertaining to the services for which the Member has an issue. What Services Are Not Covered under the Guest Advantage Program? See the Evidence of Coverage’s NON-COVERED SERVICES AND SUPPLIES section. Services that are excluded in the Evidence of Coverage are also excluded under the Guest Advantage Program except: (a) Guest Advantage services are services provided outside of AmeriHealth’s Service Area
and are not required to be provided by a Member’s Primary Care Physician.
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AMERIHEALTH HMO, INC.
RIDER TO THE HMO EVIDENCE OF COVERAGE (“RIDER”)
This Rider modifies the Small Employer Health Maintenance Organization (HMO) Evidence of Coverage by modifying the standard HMO benefits. This Rider: (a) Modifies the SCHEDULE OF SERVICES AND SUPPLIES section; (b) Modifies the DEFINITIONS section; (c) Modifies the COVERAGE PROVISION section; (d) Modifies the COVERED SERVICES AND SUPPLIES section. 1. The SCHEDULE OF SERVICES AND SUPPLIES section is modified to include the
following:
a. ORTHOTIC DEVICES 50%
PROSTHETIC DEVICES 50%
b. For all Inpatient Hospital Services, the HMO will waive the copayment for readmissions or transfers within ten (10) days of the discharge for any diagnosis.
2. The following new terms are added to the DEFINITIONS section:
ORTHOTIC DEVICES – means the following orthotics. An Orthotic Device is not an Orthotic Appliance.
A. Elastic Knee Braces; B. Prefabricated orthotics; C. Cervical collars; D. Arch supports where required for the prevention or treatment of complications
associated with diabetes;
E. Over the counter corsets; F. Elastic hose; G. Thoracic Rib Belts; H. Fabric and elastic supports such as socks; I. Dental orthotics; and J. Other similar devices. PROSTHETIC DEVICES – devices (except dental prosthetics and Prosthetic Appliances) which replace all or part of: (1) an absent body organ including contiguous tissue; or (2) the function of a permanently inoperative or malfunctioning body organ. A Prosthetic Device is not a Prosthetic Appliance.
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3. The COVERAGE PROVISION section is modified to include the following:
DEDUCTIBLE CARRYOVER Expenses incurred for Covered Services and Supplies in the last three (3) months of a calendar year which were applied to that calendar year’s Deductible will be applied to the Deductible of the next calendar year.
4. The COVERED SERVICES AND SUPPLIES section is modified to include the following:
1. Diabetic Education. Outpatient diabetic education program of diabetes self-management education including information on proper diet, provided by a:
(a) Dietician registered by a nationally recognized professional association of
dieticians; (b) Health care professional recognized as a certified diabetes educator by
the American Association of Diabetes Educators; or (c) Registered Pharmacist qualified with regard to management education for
diabetes by any institution recognized by the board of pharmacy in the State of Issue.
Benefits are provided for an Outpatient diabetic education program when the Primary Care Physician, Participating Primary Care Provider, Participating Specialist or nurse practitioner/clinical nurse specialist determines that such a program is Medically Necessary and Appropriate for the proper self-management and treatment of the Member’s diabetic condition at first diagnosis. Benefits are payable for a program prescribed:
A. At first diagnosis of diabetes; B. If upon diagnosis by a Physician, or nurse practitioner/clinical nurse
specialist of a significant change in the Member’s symptoms or conditions which necessitates changes in the Member’s self-management; and
Upon determination of the Physician or nurse practitioner/clinical nurse specialist that re-education or refresher education is necessary.
2. Orthotic Devices benefits will be provided for:
A. The initial purchase (per medical episode) of orthotic devices except foot
orthotics; and B. The replacement of orthotics except foot orthotics, for Dependent children
when required due to natural growth.
The benefit does not apply to Orthotic Appliances or Prosthetic Appliances as mandated by New Jersey law.
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3. Prosthetic Devices Benefits will be provided for Prosthetic Devices required as a result of illness or
injury. This benefit does not apply to Prosthetic Appliances or Orthotic Appliances as mandated by New Jersey law.
Benefits include but are not limited to:
1. The purchase and fitting, and the necessary adjustments and repairs, of
Prosthetic Devices and supplies (except dental prostheses) are covered. The devices or supplies must replace all or part of an absent body organ and its adjoining tissues or replace all or part of the function of a permanently useless or malfunctioning body organ.
2. Supplies and replacement of parts necessary for the proper functioning of
the Prosthetic Device;
3. With respect to visual Prosthetics when Medically Necessary and Prescribed for one of the following conditions:
a. Initial contact lenses Prescribed for the treatment of infantile
glaucoma;
b. Initial pinhole glasses Prescribed for use after surgery for detached retina;
c. Initial corneal or scleral lenses Prescribed in connection with the
treatment of keratoconus or to reduce a corneal irregularity (other than astigmatism);
d. Initial scleral lenses Prescribed to retain moisture in cases where
normal tearing is not present or adequate; and
e. An initial pair of basic eyeglasses when Prescribed to perform the function of
a human lens lost (aphakia) as a result of Accidental Injury; trauma; or ocular surgery.
The “Repair and Replacement” paragraphs set forth below do not apply to this item 3. Benefits are provided for the replacement of a previously approved Prosthetic
Device with an equivalent Prosthetic Device when:
a. There is a significant change in the Member’s condition that requires a replacement;
b. The Prosthetic Device breaks because it is defective;
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c. The Prosthetic Device breaks because it has exceeded its life duration as determined by the manufacturer; or
d. The Prosthetic Device needs to be replaced for a Dependent child due to the normal growth process when Medically Necessary.
Benefits will be provided for the repair of a Prosthetic Device when the cost to repair is less than the cost to replace it. Repair means the restoration of the Prosthetic Device or one of its components to correct problems due to wear or damage. Replacement means the removal and substitution of the Prosthetic Device or one of its components necessary for proper functioning. The HMO will neither replace nor repair the Prosthetic Device due to abuse or loss of the item.
This Rider is a part of the Evidence of Coverage. Except as stated above, nothing in this Rider changes or affects any other terms of the Evidence of Coverage.
Michael A. Munoz Senior Vice President Marketing & Sales
AMERIHEALTH HMO, INC. (Hereafter referred to as "the HMO")
RIDER FOR PRESCRIPTION DRUG COVERAGE
CARD/MAIL Contract Holder: Group Contract No.: Effective Date: This Prescription Drug Coverage Rider replaces the description of Prescription Drug coverage specified under the Evidence of Coverage to which this Rider is attached when Prescription Drugs are obtained from a: A. Participating Retail Pharmacy, Participating Retail Plus Pharmacy, or a Participating Mail Service
Pharmacy ; or B. Non-Participating Pharmacy in the case of an Emergency or Urgent Care.
SUMMARY OF BENEFITS
The Prescription Drug benefits shall be available for Covered Drugs Or Supplies dispensed pursuant to a Prescription Drug Order or Refill for the out-of-Hospital use of the Member. Prescription Drug benefits are subject to the Copayment or Coinsurance shown in the PRESCRIPTION DRUG SCHEDULE OF COST-SHARING & LIMITATIONS section of this Rider.
When a Copayment applies to a Prescription Drug Order or Refill then Coinsurance does not apply to that order or refill. When a Coinsurance applies to a Prescription Drug Order or Refill, then a Copayment does not apply to that order or refill. The Member, or his or her Practitioner acting on their behalf, may appeal any denial of benefits or application of higher Copayment or Coinsurance through the Appeal Procedures described in the Evidence of Coverage.
The HMO covers Prescription Drugs to treat an Illness or Injury and Contraceptive Drugs or Devices which require a Practitioner’s prescription. In certain cases, the HMO may determine that the use of certain Covered Drugs or Supplies for a Member’s medical condition requires Preapproval for Medical Necessity and Appropriateness. In certain cases where the HMO determines there may be Prescription Drug usage by a Member that exceeds what is generally considered appropriate under the circumstances, the HMO shall have the right to direct that Member to one pharmacy for all future Covered Drugs or Supplies. Following are the benefits provided for Covered Drugs Or Supplies:
Drugs From a Participating Pharmacy – Benefits are provided for Covered Drugs or Supplies furnished by a Participating Retail Pharmacy or a Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy subject to the applicable Prescription Drug Copayment or Coinsurance for that Prescription Drug Order or Refill. Covered Drugs or Supplies furnished by a Participating Retail Pharmacy, Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy will be covered at 100% for the remainder of the Calendar year for the Member after the Annual Out-Of-Pocket Maximum is reached by the Member. (The Member’s Prescription Drug Copayment, or Coinsurance, becomes zero percent (0%). Copayments, Coinsurance, Limitations and maximums are listed on the PRESCRIPTION DRUG SCHEDULE OF COST-SHARING & LIMITATIONS.
The Prescription Drug benefits will result in a cost to the Member of no more than 50% of the HMO’s contracted cost of the Prescription Drug, for Prescription Drugs furnished by a Participating Retail Pharmacy , Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy.
Drugs From a Non-Participating Pharmacy other than a Mail Service Pharmacy – Benefits are provided for Covered Drugs or Supplies furnished by a Non-Participating Pharmacy other than a Mail Service Pharmacy, subject to the Prescription Drug Coinsurance when the Member submits to the HMO acceptable proof of payment with a direct reimbursement form. The Member's coinsurance will not exceed fifty percent (50%) of the charge. When a Non-Participating Pharmacy furnishes Covered Drugs or Supplies related to Covered Services or Supplies for Emergency or Urgent Care out of the Service Area reimbursement will be one hundred percent (100%) less the Prescription Drug Copayment or Coinsurance. Such care must be provided in accordance with the HMO's policies and procedures. The Member must submit to the HMO acceptable proof of payment with a direct reimbursement form. All claims for payment must be received by the HMO or the HMO's agent within ninety (90) days of the date of proof of purchase or as soon as reasonably possible. Direct reimbursement forms may be obtained by contacting Customer Service.
Prescribing Practitioner – Covered Drugs or Supplies, including Maintenance Prescription Drugs, Prescribed by a Practitioner or the treating specialist in the HMO's network, and furnished by a Participating Retail Pharmacy or a Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy are covered by the plan.
Generically equivalent pharmaceuticals will be dispensed whenever applicable, unless the Practitioner or Member requests the Brand Name Drug be dispensed as written.
Contraceptive Drugs or Devices – Including, but not limited to, oral contraceptives (birth control pills), IUD (intrauterine devices), diaphragms, and injectable contraceptives are Covered Drugs or Supplies. There is no Prescription Drug Copayment, or Coinsurance, requirement for Contraceptive Drugs and Devices, and injectable contraceptives or generic oral contraceptives when furnished by a Participating Retail Pharmacy , Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy .
Dermatological Drugs – Prescription Drug benefits cover compounded dermatological preparations containing at least one federal Legend or State Restricted Drug.
Infant Formula – Covered Drugs or Supplies include specialized, non-standard infant formulas as required under P.L. 2002, C. 361 (C. 26:2J-4.25) when: A. The covered infant's Practitioner has diagnosed the infant as having multiple food protein
intolerance and has determined such formula to be Medically Necessary and Appropriate; and
B. The covered infant has not been responsive to trials of standard non-cow milk-based formulas,
including soybean and goat milk. For the purpose of this section, infants are defined as Dependent children twelve (12) months of age or younger. This coverage is subject to Preapproval, including periodic review of the continued Medical Necessity and Appropriateness of the specialized infant formula Specialized, non-standard infant formula cannot be obtained through a Participating Mail Service Pharmacy or a Non-Participating Mail Service Pharmacy.
Insulin – Insulin is an over-the-counter drug. However, the Member must obtain a Prescription Drug Order or Refill for insulin: (1) to ensure the insulin is for the Member; (2) for the HMO's adjudication system; and (3) for the HMO's pharmacy audit function. Coverage includes insulin, oral agents, disposable insulin needles and syringes, diabetic blood testing strips, lancets and glucometers. There is no Prescription Drug Copayment or Coinsurance requirement for lancets and glucometers obtained through a Participating Retail Pharmacy or a Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy .
Orally Administered Anti-Cancer Prescription Drugs – Prescription Drug benefits are provided for Prescribed, orally administered anti-cancer Prescription Drugs that are Medically Necessary and Appropriate. These drugs are used to kill or slow the growth of cancerous cells. There is no Prescription Drug Copayment, or Coinsurance, requirement for these Prescription Drugs when furnished by a Participating Retail Pharmacy or a Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy .
Over-the-Counter Drugs – Prescription Drug benefits do not cover over-the-counter drugs except insulin.
Pharmacy Charges – The HMO does not prohibit a Participating or Non-Participating Pharmacy from charging a Member for services that are in addition to charges for the Prescription Drug, for dispensing the Prescription Drug, or for Prescription Drug counseling. Services for which a Participating or Non-Participating Pharmacy may impose additional charges are subject to the approval of the State Board of Pharmacy. Prior to dispensing a Prescription Drug, the Participating or Non-Participating Pharmacy must disclose to the Member all charges for additional services in connection with dispensing that Prescription Drug, and the Member’s out-of-pocket cost for those services. A Participating or Non-Participating Pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or state or federal law.
Quantity Level Limits – Prescription Drug benefits may be subject to dispensing limits as conveyed by the Food and Drug Administration (“FDA”) or the HMO’s Pharmacy and Therapeutics Committee. Where quantity level limits are imposed, the Member's Practitioner may request an exception for coverage by providing documentation that the dosage of the drug is Medically Necessary and Appropriate. Any quantity level limit for Covered Drugs or Supplies as identified by the HMO’s Pharmacy and Therapeutics Committee will comply with the ninety (90) day dispensing requirement established under New Jersey law.
Self-Injectable Medications – Benefits are provided for Self-Injectable Prescription Drugs.
Specialty Drugs - The HMO will only provide benefits for covered Specialty Drugs through the pharmacy benefits manager’s (PBM’s) Specialty Pharmacy Program for the appropriate cost sharing indicated in the PRESCRIPTION DRUG SCHEDULE OF COST-SHARING &
LIMITATIONS for Participating Pharmacies. Benefits are available for up to a thirty (30) day supply. If the Member's doctor wants the Member to start the drug immediately, an initial supply may be obtained at a retail Pharmacy. However, all subsequent fills must be purchased through the PBM’s Specialty Pharmacy Program. No benefits shall be provided for Prescription Drugs obtained from a Specialty Pharmacy Program other than the PBM’s Specialty Pharmacy Program. The responsibility to initiate the Specialty Pharmacy process is the Member’s.
Select Specialty Drugs will be subject to ‘split fill’ whereby the initial prescription will be dispensed in two separate amounts. The first amount is dispensed without delay. The second amount may be dispensed subsequently, allowing time for any necessary clinical intervention due to medication side effects that may require dose modification or therapy discontinuation. The Member's cost share is prorated for each amount of the split fill.
Vitamins that require a Prescription Drug Order or Refill are covered by the plan.
PREAPPROVAL REQUIREMENT The HMO requires Preapproval (by the Member's Practitioner) for certain drugs to ensure the Prescribed drug is Medically Necessary and Appropriate. If a Member’s Practitioner writes a Prescription Drug Order or Refill for a drug that requires Preapproval, and Preapproval has not already been obtained by the Practitioner, a Participating Retail Pharmacy or Participating Retail Plus Pharmacy is instructed to release a 96-hour supply of the Prescription Drug to the Member without Preapproval. No Prescription Drug Copayment or Coinsurance is taken. On the following business day, the HMO's Pharmacy Services Department calls the Member’s Practitioner (whether in-network or out-of-network) to request that they submit the documentation that would have supported Preapproval of the Prescription Drug. As soon as such Preapproval documentation has been verified and approved by the HMO, the Covered Prescription Drug Order or Refill (not otherwise excluded under the plan) will be filled and no penalty will be applied. The applicable Prescription Drug Copayment or Coinsurance will apply. In the event the HMO does not approve the Preapproval documentation, the Member or his or her Practitioner acting on the Member's behalf, may appeal the decision. See the APPEALS PROCEDURE in the Evidence of Coverage.
ADDITIONAL INFORMATION ABOUT PHARMACY BENEFIT OPERATIONS
A pharmacy benefits management company (PBM), which is affiliated with the HMO, administers the Prescription Drug benefits, and is responsible for providing a network of Participating Pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. The HMO anticipates that it will pass on a high percentage of the expected rebates it receives from the HMO's PBM through reductions in the overall cost of Prescription Drug benefits. Under most benefit plans, Prescription Drugs are subject to Member cost-sharing.
IMPORTANT DEFINITIONS
BRAND NAME DRUG (BRAND NAME) – a drug manufactured by one company awarded the original patent for that specific drug or combination of drugs and satisfying requirements of the FDA and applicable state law and regulations. For the purposes of this coverage devices known as spacers for metered dose inhalers that are used to enhance the effectiveness of inhaled medicines and specialized, non-standard infant formula that is covered as required under P.L. 2002, C. 361 (C. 26:2J-4.25) will be considered a Brand Name Drug. CONTRACEPTIVE DRUGS OR DEVICES –FDA approved drugs or devices requiring a Prescription Drug Order or Refill to be dispensed. These include oral contraceptives, such as birth control pills, as well as injectable contraceptive drugs. CONTROLLED SUBSTANCE – any medicinal substance as defined by the Drug Enforcement Administration which requires a Prescription Drug Order or Refill in accordance with the Controlled Substance Act-Public Law 91-513. COVERED DRUG OR SUPPLY- Prescription Drugs, including Self-Administered Prescription Drugs, which are: A. Prescribed for a Member by a Professional Provider who is appropriately licensed to prescribe
Drugs; B. Prescribed for a use that has been approved by the Federal Food and Drug Administration; and C. Medically Necessary, as determined by the HMO. Insulin shall be considered a Covered Drug where Medically Necessary.
For the purposes of this coverage, also considered as Prescription Drugs will be: A. Specialized, non-standard infant formulas, consistent with the requirements of applicable law and
the terms stated in the COVERED SERVICES AND SUPPLIES, which standardly do not require a Prescription Drug Order or Refill, but will require a Prescription Drug Order or Refill for coverage under this plan; and
B. Diabetic supplies, such as strips, lancets and glucometers, which standardly do not require a
Prescription Drug Order or Refill, but will require a Prescription Drug Order or Refill for coverage under this benefit.
GENERIC DRUG – pharmacological agents approved by the FDA as a bioequivalent substitute and manufactured by a number of different companies as a result of the expiration of the original patent. LEGEND DRUG – any medicinal substance which is required by the federal Food, Drug, and Cosmetic Act to be labeled as follows:
"Caution: Federal Law prohibits dispensing without a prescription." MAINTENANCE PRESCRIPTION DRUG – a Covered Drug or Supply, as determined by the HMO, used for the treatment of chronic or long term conditions including, but not limited to, cardiac disease, hypertension, diabetes, lung disease and arthritis. NON-PARTICIPATING MAIL SERVICE PHARMACY – a pharmacy which has not entered into a written agreement with the HMO, or one of the HMO's agents, to dispense Covered Drugs or Supplies to Members.
NON-PARTICIPATING PHARMACY – a pharmacy which has not entered into a written agreement with the HMO, or one of the HMO's agents, to dispense Covered Drugs or Supplies to Members. PARTICIPATING MAIL SERVICE PHARMACY – a registered, licensed pharmacy, other than a Participating Retail Pharmacy or Participating Retail Plus Pharmacy, with which the HMO, or one of its agents, have contracted to dispense Covered Drugs or Supplies to Members through the mail and/or directly at its location where permitted by the HMO. PARTICIPATING PHARMACY – a Participating Retail Pharmacy , Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy . PARTICIPATING RETAIL PHARMACY – a registered, licensed pharmacy other than a Participating Retail Plus or Participating Mail Service Pharmacy with which the HMO or its agent has contracted to dispense Covered Drugs or Supplies to Members directly. PARTICIPATING RETAIL PLUS PHARMACY – a pharmacy, other than a Participating Retail Pharmacy or a Participating Mail Service Pharmacy, with which the HMO or its agent has contracted to dispense Covered Drugs or Supplies to Members directly. In order to become a Participating Retail Plus Pharmacy, a pharmacy must have agreed, in writing, to all the same terms, conditions, price and service provisions as apply to the Participating Mail Service Pharmacies. PHARMACIST – an individual duly licensed to practice the profession of pharmacology by the State Board of Pharmacy or other governing body having jurisdiction, and who is employed by or associated with, a pharmacy. PHARMACY AND THERAPEUTICS COMMITTEE – a group composed of health care professionals with recognized knowledge and expertise in clinically appropriate prescribing, dispensing and monitoring of outpatient drugs or drug use review, evaluation and intervention. The membership of the committee consists of at least two-thirds licensed and actively practicing physicians and Pharmacists and shall consist of at least one Pharmacist. PREAPPROVAL or PREAPPROVED – The approval which the treating Practitioner in the HMO's network must obtain from the HMO for specified Covered Drugs or Supplies to confirm Medical Necessity and Appropriateness of the drug for a Member’s medical condition. Such approval must be obtained prior to providing the Prescription Drug. The Member may call Customer Service at the telephone number shown on the ID Card to find out if the Prescription Drug has been Preapproved by the HMO or may ask the treating Practitioner in the HMO's network to call Provider Services. Prescription Drugs or Supplies which have not been Pre-approved and are not Medically Necessary and Appropriate are not covered. The HMO also reserves the right to apply eligible quantity level limits for certain Covered Drugs as conveyed by the FDA or the HMO's Pharmacy and Therapeutics Committee. However, any quantity level limit for Covered Drugs or Supplies as identified by the HMO's Pharmacy and Therapeutics Committee will comply with the 90 day dispensing requirement established under New Jersey law. PRESCRIBE (PRESCRIBED) – to write or give a Prescription Drug Order or Refill. PRESCRIPTION DRUG – a Legend Drug subject to the exclusions listed in the Evidence of Coverage (including those listed in this Prescription Drug Rider's NON-COVERED SERVICES AND SUPPLIES section), which has been approved by the FDA and which can, under federal or state law, be dispensed only pursuant to a Prescription Drug Order or Refill.
For the purposes of this coverage, insulin and specialized non-standard infant formulas will be considered Prescription Drugs and will require a Prescription Drug Order or Refill. Any drug and/or medication that may be dispensed without a Practitioner’s Prescription Drug Order or Refill will not be considered a Prescription Drug. This definition includes insulin and spacers for metered dose inhalers obtained with a Prescription Drug Order or Refill.
Any drug which the FDA has determined to be contraindicated for the specific treatment for which the drug has been Prescribed will be considered Experimental or Investigational. PRESCRIPTION DRUG ALLOWED AMOUNT – the dollar amount for a Covered Drug or Supply upon which the Member’s cost will be determined. The Prescription Drug Allowed Amount varies, based on where the Prescription Drug Order or Refill is dispensed. PRESCRIPTION DRUG COINSURANCE – The percentage of the Prescription Drug Allowed Amount that must be paid by a Member. The Prescription Drug Coinsurance amount is shown in the PRESCRIPTION DRUG SCHEDULE OF COST-SHARING & LIMITATIONS for Prescription Drugs of this Rider. A. If the Covered Drug or Supply is dispensed by a Participating Pharmacy , Participating Retail Plus
Pharmacy, or a Participating Mail Service Pharmacy , the amount is determined by the pharmacy agreement.
B. If the Covered Drug or Supply is dispensed by a Non-Participating Pharmacy, it is the lesser of (a)
the Non-Participating Pharmacy’s charges for the Covered Drug or Supply or (b) [100% – 150%] of the Average Wholesale Price for the Covered Drug or Supply. The Prescription Drug Allowed Amount may differ from the Non-Participating Pharmacy’s charge. Any difference will be the responsibility of the Member.
PRESCRIPTION DRUG COPAYMENT – the amount as shown in the PRESCRIPTION DRUG SCHEDULE OF COST-SHARING AND LIMITATIONS charged to the Member by the Participating Retail Pharmacy , Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy for the dispensing or refilling of any Prescription Drug. The Member is responsible at the time of service for payment of the Prescription Drug Copayment directly to the Participating Retail Pharmacy , Participating Retail Plus Pharmacy, or a Participating Mail Service Pharmacy . PRESCRIPTION DRUG ORDER OR REFILL – the authorization for a Prescription Drug, issued by a Practitioner who is duly licensed to make such an authorization in the ordinary course of his or her professional practice. SELF-ADMINISTERED PRESCRIPTION DRUG - a Prescription Drug that can be administered safely and effectively by either the Member or a caregiver, without medical supervision, regardless of whether initial medical supervision and/or instruction is required. Examples of Self-Administered Prescription Drugs include, but are not limited to:
Oral drugs;
Self-Injectable Drugs;
Inhaled drugs; and
Topical drugs. SELF-INJECTABLE PRESCRIPTION DRUG (SELF-INJECTABLE DRUG) - A Prescription Drug that: A. Is introduced into a muscle or under the skin with a syringe and needle; and
B. Can be administered safely and effectively by either the Member or a caregiver without medical supervision, regardless of whether initial medical supervision and/or instruction is required.
STATE RESTRICTED DRUG – any non-federal Legend Drug which, according to state law, may not be dispensed without a Prescription Drug Order or Refill.
PRESCRIPTION DRUG SCHEDULE OF COST SHARING & LIMITATIONS
Maximum Out-of-Pocket All covered Prescription Drug costs that a Member pays as a Copayment, Deductible and Coinsurance will be applied towards their Maximum Out-of-Pocket limit as shown in the Schedule of the medical plan.
RETAIL PHARMACIES
Generic Drugs Brand Name Drugs
Participating Retail Pharmacy:
90 day quantity increments covered at 100% after one (1) or two (2) Copayment(s) of $7
90 day quantity increments covered at 100% after one (1) or two (2) Copayment(s) of 50%
Participating Retail Plus Pharmacy:
90 day supply covered at 100% after one (1) or two (2) Copayment(s) of $7
90 day supply covered at 100% after one (1) or two (2) Copayment(s) of 50%
MAIL ORDER PHARMACIES
Participating Mail Service Pharmacy:
90 day quantity increments covered at 100% after one (1) or two (2) Copayment(s) of $7
90 day quantity increments covered at 100% after one (1) or two (2) Copayment(s) of 50%
Non-Participating Mail Service Pharmacy:
Not Covered
Not Covered
*Except for Emergency or Urgent Care. See the Covered Services and Supplies section for coverage information.
Note: When the cost of a Prescription Drug is lower than the Copayment or Coinsurance, the Member will only be responsible for the cost of the Prescription Drug.
After the Copayment or Coinsurance is paid, the HMO will pay the covered charge in excess of the Copayment or Coinsurance for each Prescription Drug dispensed by the Participating Pharmacy or Non-Participating Retail Pharmacy while the Member is insured. What the HMO pays is subject to the terms of the Evidence of Coverage.
PRESCRIPTION DRUG LIMITATIONS A. A pharmacy need not dispense a Prescription Drug Order or Refill which, in the Pharmacist's
professional judgment, should not be filled without first consulting with the prescribing Practitioner. B. The quantity of a Covered Drug or Supply dispensed from a pharmacy pursuant to a Prescription
Drug Order or Refill is limited to ninety (90) consecutive days or the maximum allowed dosage as prescribed by law, whichever is less. Ninety- (90) day supply of a Maintenance Prescription Drug may be obtained for one (1) or two (2) Prescription Drug Copayments through the Participating Mail Service Pharmacy.
C. Prescription Drug Refills will not be provided beyond six (6) months from the most recent dispensing date on Controlled Substances, and beyond one (1) year for all other Prescription Drug Refills.
D. Prescription Drug Refills will be dispensed only if 75% of the previously dispensed quantity has
been consumed based on the dosage Prescribed. E. When visiting a Participating Retail Pharmacy, the Member must present his or her Identification
Card, and the existence of Prescription Drug coverage must be indicated on the card. F. A Member shall pay to a Participating Retail Pharmacy:
1. One hundred percent (100%) of the cost for a Prescription Drug dispensed when the Member fails to show his or her Identification Card. A claim for reimbursement for Covered Drugs or Supplies may be submitted to the HMO; or
2. One hundred percent (100%) of a non-Covered Prescription Drug; or 3. The Prescription Drug Copayment or Coinsurance as specified in the PRESCRIPTION DRUG
SCHEDULE OF COST-SHARING & LIMITATIONS; or 4. When a Covered Prescription Drug is available as a Generic Drug, the HMO will only provide
benefits for that Prescription Drug at the Generic Drug level, subject to the following. If the prescribing physician indicates that the Brand Name Drug must be dispensed, the Member is responsible for the Brand Name Drug Copayment or Coinsurance amount. However, if the Member requests the Brand Name Drug, the Member is responsible for paying the dispensing pharmacy the difference between the amount payable by the HMO for the Generic Drug and amount that the HMO would have paid for the Brand Name Drug, plus the applicable Copayment or Coinsurance;
G. The HMO may determine that the use of certain Covered Drugs or Supplies for a Member’s medical
condition requires Preapproval for Medical Necessity and Appropriateness. H. The HMO reserves the right to apply eligible quantity level limits for certain Covered Drugs or
Supplies as conveyed by the FDA or the HMO's Pharmacy and Therapeutics Committee. However, any quantity level limit for Covered Drugs or Supplies as identified by the HMO's Pharmacy and Therapeutics Committee will comply with the 90 day dispensing requirement established under New Jersey law.
NON-COVERED SERVICES AND SUPPLIES
The following are not Covered Services or Supplies with respect to services and supplies for Prescription Drugs under the Evidence of Coverage. 1. Devices or supplies of any type except for FDA approved devices used for contraceptive purposes.
This exclusion applies even though such devices may require a Prescription Drug Order or Refill. These devices or supplies include, but are not limited to: therapeutic devices; artificial appliances; non-disposable hypodermic needles or devices used to assist in insulin injection (except disposable syringes for use in treatment of diabetes); support garments or other devices, regardless of their intended use, except as specified as a basic benefit in the Evidence of Coverage. This exclusion does not apply to (a) devices used for the treatment or maintenance of diabetic conditions, such as glucometers and syringes used for the injection of insulin, and (b) devices known as spacers for metered dose inhalers that are used to enhance the effectiveness of inhaled medicines.
2. Drugs Prescribed and administered in the Practitioner’s office; 3. Drugs which do not by federal or state law require a Prescription Drug Order or Refill (i.e., over-the-
counter or over-the-counter equivalents) whether or not Prescribed by a Practitioner. This does not include insulin and specialized, non-standard formulas for infants as mandated by P.L. 2002, c.361 (c. 26:2J-4.25) when Prescribed by a Practitioner;
4. Any drugs covered under another provision of the Evidence of Coverage;
5. Except as stated below, charges for drugs needed due to an on-the-job or job-related Injury or
Illness; or conditions for which benefits are payable by Workers’ Compensation, or similar laws.
Exception: This Exclusion does not apply to the following persons for whom coverage under workers’ compensation is optional unless such persons are actually covered for workers’ compensation: a self-employed person or a partner of a limited liability partnership, Members of a limited liability company or partners of a partnership who actively perform services on behalf of the self-employed business, the limited liability partnership, limited liability company or the partnership;
6. Medication for a Member confined to a rest home, Skilled Nursing Center, sanitarium, extended
care facility, Hospital or similar entity; 7. Medication furnished by any other medical service for which no charge is made to the Member; 8. Any charge where the cost of the Prescription Drug is less than the Member's Prescription Drug
Copayment or Coinsurance;
9. Any Covered Drug or Supply which is administered at the time and place of the Prescription Drug Order or Refill;
10. Any charges for the administration of Legend Drugs or injectable insulin;
11. Prescription Drugs dispensed by Non-Participating Pharmacies, except as specified for Emergency
or Urgent Care; 12. Prescription Drug Refills resulting from loss or theft, or any unauthorized Refills; 13. Immunization agents, biological sera, blood or plasma, or allergy serum; 14. Experimental or Investigational drugs, or drugs Prescribed for experimental indications when such
drugs are not recognized to be Medically Necessary and Appropriate, for the specific treatment for which the drug has been Prescribed in one of the established reference compendia described in the definition of Prescription Drug;
15. Prescription Drugs Prescribed or used for cosmetic purposes; including but not limited to, anaboloic
steroids, when such drugs are not recognized to be Medically Necessary and Appropriate for the treatment for which the drug has been Prescribed, unless Prescribed to treat medically diagnosed congenital defects and birth abnormalities in dependents who have been covered under the policy from the moment of birth;
16. Nicotine patches or gum or any other pharmacological therapy for smoking cessation;
17. Pharmacological therapy for weight reduction or diet agents; 18. Injectable drugs excluding injectable drugs used for the primary purpose of treating infertility or
injectable drugs for fertilization;
19. Injectable drugs covered elsewhere under the HMO Evidence of Coverage when administered and/or monitored by a Member’s Practitioner or health care Facility, and are not otherwise excluded under the plan;
20. Prescription Drugs not Preapproved by the HMO, if required, and are not Medically Necessary and Appropriate or Prescribed drug amounts exceeding the quantity level limits as conveyed by the FDA or the HMO's Pharmacy and Therapeutics Committee. However, any quantity level limit for Covered Drugs or Supplies as identified by the HMO’s Pharmacy and Therapeutics Committee will comply
with the 90 day dispensing requirement established under New Jersey law;
21. Human growth hormones;
22. Sildefanil (Viagra), alprostadil (Caverject, MUSE), and related drugs used to treat erectile dysfunction, regardless of the specified indication for prescribing, and regardless of patient gender. This exclusion does not include hormonal replacement therapy, or drugs used to treat other conditions where sexual dysfunction may be a comorbid condition (e.g.; treatment of depression with antidepressants);]
23. Prescription Drugs that are covered elsewhere under the HMO Evidence of Coverage when
administered and/or monitored by a Member’s Practitioner or health care Facility, including a Home Health Care or Hospice facility, and are not otherwise excluded under the plan;
24. Injectable drugs excluding (1) injectables used for the primary purpose of treating infertility or for fertilization and (2) Injectable Contraceptive Drugs or Devices [for other than the use of contraception or when necessary to preserve the life and health of a Member;]
25. Certain types of Prescription Drugs may not be available through Mail Service Pharmacies, including, but not limited to: a. Prescription Drugs that cannot be dispensed in accordance with the dispensing protocols of the
HMO, or the Mail Service Pharmacy; b. Non-standard infant formulas even if they would otherwise qualify as Prescription Drugs; c. Prescription Drugs that pose safety and/or stability issues, such as medications that contain
dangerous or flammable chemicals, biohazardous drugs, or drugs that require monitoring; d. Prescription Drugs that require special record-keeping procedures; and e. Prescription Drugs that require specialized compounding equipment.
26. Specialized, non-standard infant formula that is purchased without a Prescription Drug Order or Refill or otherwise fails to satisfy the requirements for coverage stated in SUMMARY OF BENEFITS of this Rider.
27. All infant formulas, nutritional formulas and nutritional supplements, except specialized, non-standard infant formulas that satisfy the requirements for coverage stated in SUMMARY OF BENEFITS of this Rider.
REMEMBER: Refer to the APPEALS PROCEDURES section in the Evidence of Coverage for
information about addressing any questions or resolving any problems the Member may have.
(Example: the application of a Non-Formulary Drug Copayment or denial of coverage for a Prescription
Drug.)
This Rider is a part of the Evidence of Coverage. Except as stated above, nothing in this Rider changes or affects any other terms of the Evidence of Coverage. AmeriHealth HMO, Inc.
AMERIHEALTH NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION _______________________
PLEASE REVIEW IT CAREFULLY.
AmeriHealth2 values you as a customer, and protection of your privacy is very important to us. In conducting our business, we will create and maintain records that contain protected health information about you and the health care provided to you as a member of our health plans. Note: “Protected health information” or “PHI” is information about you, including information that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care. We protect your privacy by:
limiting who may see your PHI;
limiting how we may use or disclose your PHI;
informing you of our legal duties with respect to your PHI;
explaining our privacy policies; and
adhering to the policies currently in effect. This Notice describes our privacy practices, which include how we may use, disclose, collect, handle, and protect our members’ protected health information. We are required by certain federal and state laws to maintain the privacy of your protected health information. We also are required by the federal Health Insurance Portability and Accountability Act (or ________________________ 1
If you are enrolled in a self-insured group benefit program, this Notice is not applicable. If you are enrolled in such a program, you should contact your Group Benefit Manager for information about your group’s privacy practices. If you are enrolled in the Federal Employee’s Service Benefit Plan, you will receive a separate Notice. 2 For purposes of this Notice, “AmeriHealth’ refers to the following companies: AmeriHealth HMO,
Inc., AmeriHealth Insurance Company of New Jersey, and QCC Insurance Company d/b/a AmeriHealth Insurance Company.
Page 3 of 8
“HIPAA”) Privacy Rule to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. This revised Notice takes effect on September 23, 2013, and will remain in effect until we replace or modify it. Copies of this Notice You may request a copy of our Notice at any time. If you want more information about our privacy practices, or have questions or concerns, please contact Member Services by calling the telephone number on the back of your Member Identification Card, or contact us using the contact information at the end of this Notice. Changes to this Notice The terms of this Notice apply to all records that are created or retained by us which contain your PHI. We reserve the right to revise or amend the terms of this Notice. A revised or amended Notice will be effective for all of the PHI that we already have about you, as well as for any PHI we may create or receive in the future. We are required by law to comply with whatever Privacy Notice is currently in effect. You will be notified of any material change to our Privacy Notice before the change becomes effective. When necessary, a revised Notice will be mailed to the address that we have on record for the contract holder of your member contract, and will also be posted on our web site at www.amerihealth.com. Potential Impact of State Law The HIPAA Privacy Rule generally does not “preempt” (or take precedence over) state privacy or other applicable laws that provide individuals greater privacy protections. As a result, to the extent state law applies, the privacy laws of a particular state, or other federal laws, rather than the HIPAA Privacy Rule, might impose a privacy standard under which we will be required to operate. For example, where such laws have been enacted, we will follow more stringent state privacy laws that relate to uses and disclosures of the protected health information concerning HIV or AIDS, mental health, substance abuse/chemical dependency, genetic testing, reproductive rights, etc. How We May Use and Disclose Your Protected Health Information (PHI) In order to administer our health benefit programs effectively, we will collect, use and disclose PHI for certain of our activities, including payment of covered services and health care operations. The following categories describe the different ways in which we may use and disclose your PHI. Please note that every permitted use or disclosure of your PHI is not listed below. However, the different ways we will, or might, use or disclose your PHI do fall within one of the permitted categories described below. Treatment: We may disclosure information to doctors, pharmacies, hospitals and other health care providers who take care of you to assist in your treatment or the coordination of your care. Payment: We may use and disclose your PHI for all payment activities including, but not limited to, collecting premiums or to determine or fulfill our responsibility to provide health care coverage under our health plans. This may include coordinating benefits with other health care programs or insurance carriers, such as Medicare or Medicaid. For example, we may use and disclose your PHI to pay claims for services provided to you by doctors or hospitals which are covered by your health plan(s), or
to determine if requested services are covered under your health plan. We may also use and disclose your PHI to conduct business with other AmeriHealth affiliate companies. Health Care Operations: We may use and disclose your PHI to conduct and support our business and management activities as a health insurance issuer. For example, we may use and disclose your PHI to determine our premiums for your health plan, to conduct quality assessment and improvement activities, to conduct business planning activities, to conduct fraud detection programs, to conduct or arrange for medical review, or to engage in care coordination of health care services. We may also use and disclose your PHI to offer you one of our value added programs like smoking cessation or discounted health related services, or to provide you with information about one of our disease management programs or other available AmeriHealth health products or health services. We may also use and disclose your PHI to provide you with reminders to obtain preventive health services, and to inform you of treatment alternatives and/or health related benefits and services that may be of interest to you. Marketing: Your PHI will not be sold, used or disclosed for marketing purposes without your authorization except where permitted by law. Such exceptions may include: a marketing communication to you that is in the form of (a) a face-to-face communication, or (b) a promotional gift of nominal value. Release of Information to Plan Sponsors: Plan sponsors are employers or other organizations that sponsor a group health plan. We may disclose PHI to the plan sponsor of your group health plan as follows:
We may disclose “summary health information” to your plan sponsor to use to obtain premium bids for providing health insurance coverage or to modify, amend or terminate its group health plan. “Summary health information” is information that summarizes claims history, claims expenses, or types of claims experience for the individuals who participate in the plan sponsor’s group health plan;
We may disclose PHI to your plan sponsor to verify enrollment/disenrollment in your group health plan;
We may disclose your PHI to the plan sponsor of your group health plan so that the plan sponsor can administer the group health plan; and
If you are enrolled in a group health plan, your plan sponsor may have met certain requirements of the HIPAA Privacy Rule that will permit us to disclose PHI to the plan sponsor. Sometimes the plan sponsor of a group health plan is the employer. In those circumstances, we may disclose PHI to your employer. You should talk to your employer to find out how this information will be used.
Research: We may use or disclose your PHI for research purposes if certain conditions are met. Before we disclose your PHI for research purposes without your written permission, an Institutional Review Board (a board responsible under federal law for reviewing and approving research involving human subjects) or Privacy Board reviews the research proposal to ensure that the privacy of your PHI is protected, and to approve the research.
Required by Law: We may disclose your PHI when required to do so by applicable law. For example, the law requires us to disclose your PHI:
When required by the Secretary of the U.S. Department of Health and Human Services to investigate our compliance efforts; and
To health oversight agencies, to allow them to conduct audits and investigations of the health care system, to determine eligibility for government programs, to determine compliance with government program standards, and for certain civil rights enforcement actions.
Public Health Activities: We may disclose your PHI to public health agencies for public health activities that are permitted or required by law, such as to:
prevent or control disease, injury or disability;
maintain vital records, such as births and deaths;
report child abuse and neglect;
notify a person about potential exposure to a communicable disease;
notify a person about a potential risk for spreading or contracting a disease or condition;
report reactions to drugs or problems with products or devices;
notify individuals if a product or device they may be using has been recalled; and
notify appropriate government agency(ies) and authority(ies) about the potential abuse or neglect of an adult patient, including domestic violence.
Health Oversight Activities: We may disclose your PHI to a health oversight agency for activities authorized by law, such as: audits; investigations; inspections; licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Health oversight agencies seeking this information include government agencies that oversee: (i) the health care system; (ii) government benefit programs; (iii) other government regulatory programs; and (iv) compliance with civil rights laws. Lawsuits and Other Legal Disputes: We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process once we have met all administrative requirements of the HIPAA Privacy Rule. Law Enforcement: We may disclose your PHI to law enforcement officials under certain conditions. For example, we may disclose PHI:
to permit identification and location of witnesses, victims, and fugitives;
in response to a search warrant or court order;
as necessary to report a crime on our premises;
to report a death that we believe may be the result of criminal conduct; or
in an emergency, to report a crime. Coroners, Medical Examiners, or Funeral Directors: We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We also may disclose, as authorized by law, information to funeral directors so that they may carry out their duties. Organ and Tissue Donation: We may use or disclose your PHI to organizations that handle organ and tissue donation and distribution, banking, or transplantation.
To Prevent a Serious Threat to Health or Safety: As permitted by law, we may disclose your PHI if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Military and National Security: We may disclose to military authorities the PHI of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials PHI required for lawful intelligence, counter-intelligence, and other national security activities. Inmates: If you are a prison inmate, we may disclose your PHI to the prison or to a law enforcement official for: (1) the prison to provide health care to you; (2) your health and safety, and the health and safety of others; or (3) the safety and security of the prison. Underwriting: We will not use genetic information about you for underwriting purposes. Workers’ Compensation: As part of your workers’ compensation claim, we may have to disclose your PHI to a worker’s compensation carrier. To You: When you ask us to, we will disclose to you your PHI that is in a “designated record set.” Generally, a designated record set contains medical, enrollment, claims and billing records we may have about you, as well as other records that we use to make decisions about your health care benefits. You can request the PHI from your designated record set as described in the section below called “Your Privacy Rights Concerning Your Protected Health Information.” To Your Personal Representative: If you tell us to, we will disclose your PHI to someone who is qualified to act as your personal representative according to any relevant state laws. In order for us to disclose your PHI to your personal representative, you must send us a completed AmeriHealth Personal Representative Designation Form or documentation that supports the person’s qualification according to state law (such as a power of attorney or guardianship). To request the AmeriHealth Personal Representative Designation Form, please contact Member Services at the telephone number listed on the back of your Member Identification card, print the form from our web site at www.amerihealth.com, or write us at the address at the end of this Notice. However, the HIPAA Privacy Rule permits us to choose not to treat that person as your personal representative when we have a reasonable belief that: (i) you have been, or may be, subjected to domestic violence, abuse or neglect by the person; (ii) treating the person as your personal representative could endanger you; or (iii) in our professional judgment, it is not in your best interest to treat the person as your personal representative. To Family and Friends: Unless you object, we may disclose your PHI to a friend or family member who has been identified as being involved in your health care. We also may disclose your PHI to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. If you are not present or able to agree to these disclosures of your PHI, then we may, using our professional judgment, determine whether the disclosure is in your best interest. Parents as Personal Representatives of Minors: In most cases, we may disclose your minor child’s PHI to you. However, we may be required to deny a parent’s access to a minor’s PHI according to applicable state law.
Right to Provide an Authorization for Other Uses and Disclosures
Other uses and disclosures of your PHI that are not described above will be made only with your written authorization.
You may give us written authorization permitting us to use your PHI or disclose it to anyone for any purpose.
We will obtain your written authorization for uses and disclosures of your PHI that are not identified by this Notice, or are not otherwise permitted by applicable law.
Any authorization that you provide to us regarding the use and disclosure of your PHI may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your authorization. We may also be required to disclose PHI as necessary for purposes of payment for services received by you prior to the date when you revoked your authorization. Your authorization must be in writing and contain certain elements to be considered a valid authorization. For your convenience, you may use our approved AmeriHealth Authorization Form. To request the AmeriHealth Authorization Form, please contact Member Services at the telephone number listed on the back of your Member Identification card, print the form from our web site at www.amerihealth.com, or write us at the address at the end of this Notice. Your Privacy Rights Concerning Your Protected Health Information (PHI) You have the following rights regarding the PHI that we maintain about you. Requests to exercise your rights as listed below must be in writing. For your convenience, you may use our approved AmeriHealth form(s). To request a form, please contact Member Services at the telephone number listed on the back of your Member Identification card or write to us at the address listed at the end of this Notice. Right to Access Your PHI: You have the right to inspect or get copies of your PHI contained in a designated record set. Generally, a “designated record set” contains medical, enrollment, claims and billing records we may have about you, as well as other records that we may use to make decisions about your health care benefits. However, you may not inspect or copy psychotherapy notes or certain other information that may be contained in a designated record set. You may request that we provide copies of your PHI in a format other than photocopies such as by electronic means in certain situations. We will use the format you request unless we cannot practicably do so. We may charge a reasonable fee for copies of PHI (based on our costs), for postage, and for a custom summary or explanation of PHI. You will receive notification of any fee(s) to be charged before we release your PHI, and you will have the opportunity to modify your request in order to avoid and/or reduce the fee. In certain situations we may deny your request for access to your PHI. If we do, we will tell you our reasons in writing, and explain your right to have the denial reviewed. Right to Amend Your PHI: You have the right to request that we amend your PHI if you believe there is a mistake in your PHI, or that important information is missing. Approved amendments made to your PHI will also be sent to those who need to know, including (where appropriate) AmeriHealth’s vendors (known as "Business Associates"). We may also deny your
request if, for instance, we did not create the information you want amended. If we deny your request to amend your PHI, we will tell you our reasons in writing, and explain your right to file a written statement of disagreement. Right to an Accounting of Certain Disclosures: You may request, in writing, that we tell you when we or our Business Associates have disclosed your PHI (an “Accounting”). Any accounting of disclosures will not include those we made:
for payment, or health care operations;
to you or individuals involved in your care;
with your authorization;
for national security purposes;
to correctional institution personnel; or
before April 14, 2003. The first accounting in any 12-month period is without charge. We may charge you a reasonable fee (based on our cost) for each subsequent accounting request within a 12-month period. If a subsequent request is received, we will notify you of any fee to be charged, and we will give you an opportunity to withdraw or modify your request in order to avoid or reduce the fee. Right to Request Restrictions: You have the right to request, in writing, that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to your request. However, if we do agree, we will be bound by our agreement except when required by law, in emergencies, or when information is necessary to treat you. An approved restriction continues until you revoke it in writing, or until we tell you that we are terminating our agreement to a restriction. Right to Request Confidential Communications: You have the right to request that we use alternate means or an alternative location to communicate with you in confidence about your PHI. For instance, you may ask that we contact you by mail, rather than by telephone, or at work, rather than at home. Your written request must clearly state that the disclosure of all or part of your PHI at your current address or method of contact we have on record could be an endangerment to you. We will require that you provide a reasonable alternate address or other method of contact for the confidential communications. In assessing reasonableness, we will consider our ability to continue to receive payment and conduct health care operations effectively, and the subscriber’s right to payment information. We may exclude certain communications that are commonly provided to all members from confidential communications. Examples of such communications include benefit booklets and newsletters. Right to a Paper Copy of This Notice: You have the right to receive a paper copy of our Notice of Privacy Practices. You can request a copy at any time, even if you have agreed to receive this Notice electronically. To request a paper copy of this Notice, please contact Member Services at the telephone number on the back of your Member Identification Card. Right to Notification of a Breach of Your PHI: You have the right to and will be notified following a breach of your unsecured PHI or if a security breach occurs involving your PHI. Your Right to File a Privacy Complaint If you believe your privacy rights have been violated, or if you are dissatisfied with AmeriHealth’s privacy practices or procedures, you may file a complaint with the AmeriHealth
Privacy Office and with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint. To file a privacy complaint with us, you may contact Member Services at the telephone number on the back of your ID card, or you may contact the Privacy Office as follows:
AmeriHealth Privacy Office P.O. Box 41762 Philadelphia, PA 19101 – 1762 Fax: 215-241-4023 or 1-888-678-7006 (toll-free) E-mail: [email protected] Phone: 215-241-4735 or 1-888-678-7005 (toll-free)
Hearing-impaired TTY users may call 711 to receive assistance free of charge. Para obtener asistencia en Español, por favor comuníquese con el Servicio de Atención al Cliente al número que figura en su tarjeta de identificación. Upang makakuha ng tulong sa Tagalog, tumawag sa numero ng telepono ng serbisyong pangkostumer na nakalista sa iyong card ng pagkikilanlan.
Táá Diné k’ehjí shíka ’adoowoł nínízingo, ninaaltsoos bee ééhózinígíí béésh bee hane’é bikáá’ bee bik’e’ashchínígíí bich’i’ hodíílnih.
